{ "hospital_name": "Northern Illinois Medical Center DBA Northwestern Medicine McHenry Hospital", "last_updated_on": "2026-04-01", "version": "3.0.0", "location_name": [ "Northwestern Medicine McHenry Hospital", "Northwestern Medicine Huntley Hospital", "Northwestern Medicine Woodstock Hospital" ], "hospital_address": [ "4201 Medical Center Drive, McHenry, IL 60050", "10400 Haligus Road, Huntley, IL 60142", "3701 Doty Road, Woodstock, IL 60098" ], "license_information": { "license_number": "0003889", "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": [ "1427065499", "1497764526", "1982611281" ], "standard_charge_information": [ { "description": "1.5MM TI CORTEX SCREW SELF-TAPPING 6MM", "code_information": [ { "code": "SUP-49999", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 26.19, "maximum": 135.69, "setting": "outpatient", "gross_charge": 135.69, "discounted_cash": 94.98, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 26.19, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 71.51, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 41.93, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $135.69 @ 12.5% = $16.96 due to $0.00 Claim Price", "median_amount": 16.96, "10th_percentile": 16.96, "90th_percentile": 16.96, "count": "0", "methodology": "other", "additional_payer_notes": "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: $135.69 @ 12.5% = $16.96 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 135.69, "10th_percentile": 135.69, "90th_percentile": 135.69, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 135.69, "10th_percentile": 135.69, "90th_percentile": 135.69, "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": "NWR BCBS PPO", "standard_charge_dollar": 46.0, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.0, "10th_percentile": 46.0, "90th_percentile": 46.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 46.0, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.0, "10th_percentile": 46.0, "90th_percentile": 46.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 39.62, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.62, "10th_percentile": 39.62, "90th_percentile": 39.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 39.62, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.62, "10th_percentile": 39.62, "90th_percentile": 39.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 48.41, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 48.41, "10th_percentile": 48.41, "90th_percentile": 48.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 48.41, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 48.41, "10th_percentile": 48.41, "90th_percentile": 48.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 48.17, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 48.17, "10th_percentile": 48.17, "90th_percentile": 48.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 72.19, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 72.19, "10th_percentile": 72.19, "90th_percentile": 72.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 46.68, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 46.68, "10th_percentile": 46.68, "90th_percentile": 46.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 94.98, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 94.98, "10th_percentile": 94.98, "90th_percentile": 94.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 67.85, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 67.85, "10th_percentile": 67.85, "90th_percentile": 67.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 99.05, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 99.05, "10th_percentile": 99.05, "90th_percentile": 99.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 41.18, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 41.18, "10th_percentile": 41.18, "90th_percentile": 41.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 135.69, "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 $135.69 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 135.69, "10th_percentile": 135.69, "90th_percentile": 135.69, "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 $135.69 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 85.48, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $85.48 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 85.48, "10th_percentile": 85.48, "90th_percentile": 85.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $85.48 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 135.69, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 135.69, "10th_percentile": 135.69, "90th_percentile": 135.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 101.77, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 101.77, "10th_percentile": 101.77, "90th_percentile": 101.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 26.73, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.73, "10th_percentile": 26.73, "90th_percentile": 26.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 87.15, "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": 87.15, "10th_percentile": 87.15, "90th_percentile": 87.15, "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": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 108.55, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 108.55, "10th_percentile": 108.55, "90th_percentile": 108.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 64.32, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 64.32, "10th_percentile": 64.32, "90th_percentile": 64.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 64.86, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 64.86, "10th_percentile": 64.86, "90th_percentile": 64.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 64.86, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 64.86, "10th_percentile": 64.86, "90th_percentile": 64.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 64.86, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 64.86, "10th_percentile": 64.86, "90th_percentile": 64.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "10 DEG ILIAC SCREW 7.5X100 TI", "code_information": [ { "code": "SUP-305539", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $0.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $0.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" } ] } ] }, { "description": "105MM PRE BENT SPHERX ROD", "code_information": [ { "code": "SUP-307196", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 289.96, "maximum": 1502.38, "setting": "outpatient", "gross_charge": 1502.38, "discounted_cash": 1051.67, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,502.38 @ 12.5% = $187.80 due to $0.00 Claim Price", "median_amount": 187.8, "10th_percentile": 187.8, "90th_percentile": 187.8, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,502.38 @ 12.5% = $187.80 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1502.38, "10th_percentile": 1502.38, "90th_percentile": 1502.38, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1502.38, "10th_percentile": 1502.38, "90th_percentile": 1502.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 516.82, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 516.82, "10th_percentile": 516.82, "90th_percentile": 516.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 751.19, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 751.19, "10th_percentile": 751.19, "90th_percentile": 751.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 295.97, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 295.97, "10th_percentile": 295.97, "90th_percentile": 295.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 1096.74, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1096.74, "10th_percentile": 1096.74, "90th_percentile": 1096.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 455.97, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 455.97, "10th_percentile": 455.97, "90th_percentile": 455.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 712.13, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 712.13, "10th_percentile": 712.13, "90th_percentile": 712.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1126.79, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1126.79, "10th_percentile": 1126.79, "90th_percentile": 1126.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 533.34, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 533.34, "10th_percentile": 533.34, "90th_percentile": 533.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 964.98, "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": 964.98, "10th_percentile": 964.98, "90th_percentile": 964.98, "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": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1201.9, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1201.9, "10th_percentile": 1201.9, "90th_percentile": 1201.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 799.27, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 799.27, "10th_percentile": 799.27, "90th_percentile": 799.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 464.24, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 464.24, "10th_percentile": 464.24, "90th_percentile": 464.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1051.67, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1051.67, "10th_percentile": 1051.67, "90th_percentile": 1051.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1502.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1502.38, "10th_percentile": 1502.38, "90th_percentile": 1502.38, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1502.38, "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 $1,502.38 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1502.38, "10th_percentile": 1502.38, "90th_percentile": 1502.38, "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 $1,502.38 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 946.5, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $946.50 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 946.5, "10th_percentile": 946.5, "90th_percentile": 946.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $946.50 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 791.75, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.47, "10th_percentile": 45.47, "90th_percentile": 45.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 289.96, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 8.1, "10th_percentile": 8.1, "90th_percentile": 8.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 509.31, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 509.31, "10th_percentile": 509.31, "90th_percentile": 509.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 509.31, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 509.31, "10th_percentile": 509.31, "90th_percentile": 509.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 536.05, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 536.05, "10th_percentile": 536.05, "90th_percentile": 536.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 536.05, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 536.05, "10th_percentile": 536.05, "90th_percentile": 536.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 438.69, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 438.69, "10th_percentile": 438.69, "90th_percentile": 438.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 438.69, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 438.69, "10th_percentile": 438.69, "90th_percentile": 438.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 718.14, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 718.14, "10th_percentile": 718.14, "90th_percentile": 718.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 718.14, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 718.14, "10th_percentile": 718.14, "90th_percentile": 718.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 718.14, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 718.14, "10th_percentile": 718.14, "90th_percentile": 718.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "2.4MM TI CRTX SCRW ST 18MM", "code_information": [ { "code": "SUP-377166", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 59.28, "maximum": 307.14, "setting": "outpatient", "gross_charge": 307.14, "discounted_cash": 215.0, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 59.28, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 161.86, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 94.91, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $307.14 @ 12.5% = $38.39 due to $0.00 Claim Price", "median_amount": 38.39, "10th_percentile": 38.39, "90th_percentile": 38.39, "count": "0", "methodology": "other", "additional_payer_notes": "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: $307.14 @ 12.5% = $38.39 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 307.14, "10th_percentile": 307.14, "90th_percentile": 307.14, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 307.14, "10th_percentile": 307.14, "90th_percentile": 307.14, "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": "NWR BCBS PPO", "standard_charge_dollar": 104.12, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 104.12, "10th_percentile": 104.12, "90th_percentile": 104.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 104.12, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 104.12, "10th_percentile": 104.12, "90th_percentile": 104.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 89.68, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 89.68, "10th_percentile": 89.68, "90th_percentile": 89.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 89.68, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 89.68, "10th_percentile": 89.68, "90th_percentile": 89.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 109.59, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 109.59, "10th_percentile": 109.59, "90th_percentile": 109.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 109.59, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 109.59, "10th_percentile": 109.59, "90th_percentile": 109.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 109.03, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 109.03, "10th_percentile": 109.03, "90th_percentile": 109.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 163.4, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 163.4, "10th_percentile": 163.4, "90th_percentile": 163.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 105.66, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 105.66, "10th_percentile": 105.66, "90th_percentile": 105.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 215.0, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 215.0, "10th_percentile": 215.0, "90th_percentile": 215.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 153.57, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 153.57, "10th_percentile": 153.57, "90th_percentile": 153.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 224.21, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 224.21, "10th_percentile": 224.21, "90th_percentile": 224.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 93.22, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 93.22, "10th_percentile": 93.22, "90th_percentile": 93.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 307.14, "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 $307.14 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 307.14, "10th_percentile": 307.14, "90th_percentile": 307.14, "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 $307.14 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 193.5, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $193.50 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 193.5, "10th_percentile": 193.5, "90th_percentile": 193.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $193.50 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 307.14, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 307.14, "10th_percentile": 307.14, "90th_percentile": 307.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 230.36, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 230.36, "10th_percentile": 230.36, "90th_percentile": 230.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 60.51, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.51, "10th_percentile": 60.51, "90th_percentile": 60.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 197.28, "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": 197.28, "10th_percentile": 197.28, "90th_percentile": 197.28, "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": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 245.71, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 245.71, "10th_percentile": 245.71, "90th_percentile": 245.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 145.58, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 145.58, "10th_percentile": 145.58, "90th_percentile": 145.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 146.81, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 146.81, "10th_percentile": 146.81, "90th_percentile": 146.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 146.81, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 146.81, "10th_percentile": 146.81, "90th_percentile": 146.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 146.81, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 146.81, "10th_percentile": 146.81, "90th_percentile": 146.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "2.5 X 22MM MEDTRONIC RESOLUTE INTEGRITY RX DRUG ELUTING STENT", "code_information": [ { "code": "SUP-142541", "type": "CDM" }, { "code": "C1874", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 579.09, "maximum": 3000.46, "setting": "outpatient", "gross_charge": 3000.46, "discounted_cash": 2100.32, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1065.16, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 8780.07, "10th_percentile": 8780.07, "90th_percentile": 8780.07, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1581.24, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1581.24, "10th_percentile": 1581.24, "90th_percentile": 1581.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC CORE", "standard_charge_dollar": 1422.22, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1422.22, "10th_percentile": 1422.22, "90th_percentile": 1422.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 1927.2, "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": 1927.2, "10th_percentile": 1927.2, "90th_percentile": 1927.2, "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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1890.29, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,890.29 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1890.29, "10th_percentile": 1890.29, "90th_percentile": 1890.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,890.29 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 910.64, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 910.64, "10th_percentile": 910.64, "90th_percentile": 910.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1500.23, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1500.23, "10th_percentile": 1500.23, "90th_percentile": 1500.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1596.24, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1596.24, "10th_percentile": 1596.24, "90th_percentile": 1596.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 579.09, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 579.09, "10th_percentile": 579.09, "90th_percentile": 579.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 1032.16, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1032.16, "10th_percentile": 1032.16, "90th_percentile": 1032.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 2400.37, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2400.37, "10th_percentile": 2400.37, "90th_percentile": 2400.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 2190.34, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 2190.34, "10th_percentile": 2190.34, "90th_percentile": 2190.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2100.32, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 2100.32, "10th_percentile": 2100.32, "90th_percentile": 2100.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 927.14, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 663.47, "10th_percentile": 663.47, "90th_percentile": 663.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2250.35, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 2250.35, "10th_percentile": 2250.35, "90th_percentile": 2250.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 591.09, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 591.09, "10th_percentile": 591.09, "90th_percentile": 591.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 1070.56, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1070.56, "10th_percentile": 1070.56, "90th_percentile": 1070.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1070.56, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1070.56, "10th_percentile": 1070.56, "90th_percentile": 1070.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 876.13, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 876.13, "10th_percentile": 876.13, "90th_percentile": 876.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 876.13, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 876.13, "10th_percentile": 876.13, "90th_percentile": 876.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 3000.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3000.46, "10th_percentile": 3000.46, "90th_percentile": 3000.46, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3000.46, "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 $3,000.46 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3000.46, "10th_percentile": 3000.46, "90th_percentile": 3000.46, "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 $3,000.46 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": "NWR BCBS PPO", "standard_charge_dollar": 1017.16, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1017.16, "10th_percentile": 1017.16, "90th_percentile": 1017.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1017.16, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1017.16, "10th_percentile": 1017.16, "90th_percentile": 1017.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1434.22, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1434.22, "10th_percentile": 1434.22, "90th_percentile": 1434.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1434.22, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1434.22, "10th_percentile": 1434.22, "90th_percentile": 1434.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1434.22, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1434.22, "10th_percentile": 1434.22, "90th_percentile": 1434.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3000.46, "10th_percentile": 3000.46, "90th_percentile": 3000.46, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3000.46, "10th_percentile": 3000.46, "90th_percentile": 3000.46, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $3,000.46 @ 12.5% = $375.06 due to $0.00 Claim Price", "median_amount": 375.06, "10th_percentile": 375.06, "90th_percentile": 375.06, "count": "0", "methodology": "other", "additional_payer_notes": "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: $3,000.46 @ 12.5% = $375.06 due to $0.00 Claim Price" } ] } ] }, { "description": "2.7MM METAPHYSEAL SCR SLF-TPNG W T8 STRDRV RECESS 10MM", "code_information": [ { "code": "SUP-377029", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 57.9, "maximum": 299.98, "setting": "outpatient", "gross_charge": 299.98, "discounted_cash": 209.99, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 57.9, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 158.09, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 92.69, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $299.98 @ 12.5% = $37.50 due to $0.00 Claim Price", "median_amount": 37.5, "10th_percentile": 37.5, "90th_percentile": 37.5, "count": "0", "methodology": "other", "additional_payer_notes": "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: $299.98 @ 12.5% = $37.50 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 299.98, "10th_percentile": 299.98, "90th_percentile": 299.98, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 299.98, "10th_percentile": 299.98, "90th_percentile": 299.98, "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": "NWR BCBS PPO", "standard_charge_dollar": 101.69, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.69, "10th_percentile": 101.69, "90th_percentile": 101.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 101.69, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.69, "10th_percentile": 101.69, "90th_percentile": 101.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 87.59, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 87.59, "10th_percentile": 87.59, "90th_percentile": 87.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 87.59, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 87.59, "10th_percentile": 87.59, "90th_percentile": 87.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 107.03, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 107.03, "10th_percentile": 107.03, "90th_percentile": 107.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 107.03, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 107.03, "10th_percentile": 107.03, "90th_percentile": 107.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 106.49, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 106.49, "10th_percentile": 106.49, "90th_percentile": 106.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 159.59, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 159.59, "10th_percentile": 159.59, "90th_percentile": 159.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 103.19, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 103.19, "10th_percentile": 103.19, "90th_percentile": 103.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 209.99, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 209.99, "10th_percentile": 209.99, "90th_percentile": 209.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 149.99, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 149.99, "10th_percentile": 149.99, "90th_percentile": 149.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 218.99, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 218.99, "10th_percentile": 218.99, "90th_percentile": 218.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 91.04, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 91.04, "10th_percentile": 91.04, "90th_percentile": 91.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 299.98, "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 $299.98 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 299.98, "10th_percentile": 299.98, "90th_percentile": 299.98, "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 $299.98 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 188.99, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $188.99 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 188.99, "10th_percentile": 188.99, "90th_percentile": 188.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $188.99 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 299.98, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 299.98, "10th_percentile": 299.98, "90th_percentile": 299.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 224.99, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 224.99, "10th_percentile": 224.99, "90th_percentile": 224.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 59.1, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 59.1, "10th_percentile": 59.1, "90th_percentile": 59.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 192.68, "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": 192.68, "10th_percentile": 192.68, "90th_percentile": 192.68, "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": "NWR BEECHSTREET", "standard_charge_dollar": 239.98, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 239.98, "10th_percentile": 239.98, "90th_percentile": 239.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 142.19, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 142.19, "10th_percentile": 142.19, "90th_percentile": 142.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 143.39, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 143.39, "10th_percentile": 143.39, "90th_percentile": 143.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 143.39, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 143.39, "10th_percentile": 143.39, "90th_percentile": 143.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 143.39, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 143.39, "10th_percentile": 143.39, "90th_percentile": 143.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "20 DEG ILIAC SCREW 8.5X50 TI", "code_information": [ { "code": "SUP-305579", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $0.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $0.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" } ] } ] }, { "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": 2.4, "maximum": 12.41, "setting": "outpatient", "gross_charge": 12.41, "discounted_cash": 8.69, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12.41, "10th_percentile": 12.41, "90th_percentile": 12.41, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12.41, "10th_percentile": 12.41, "90th_percentile": 12.41, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 4.83, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.83, "10th_percentile": 4.83, "90th_percentile": 4.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 4.83, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.83, "10th_percentile": 4.83, "90th_percentile": 4.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 4.43, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.43, "10th_percentile": 4.43, "90th_percentile": 4.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 4.43, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.43, "10th_percentile": 4.43, "90th_percentile": 4.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3.49, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.49, "10th_percentile": 3.49, "90th_percentile": 3.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3.49, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.49, "10th_percentile": 3.49, "90th_percentile": 3.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 6.04, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 2.4, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 2.4, "10th_percentile": 2.4, "90th_percentile": 2.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 6.52, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.52, "10th_percentile": 6.52, "90th_percentile": 6.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 4.41, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 4.41, "10th_percentile": 4.41, "90th_percentile": 4.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 4.27, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 4.27, "10th_percentile": 4.27, "90th_percentile": 4.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 6.6, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 6.6, "10th_percentile": 6.6, "90th_percentile": 6.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 2.44, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 9.93, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 9.93, "10th_percentile": 9.93, "90th_percentile": 9.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 12.41, "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 $12.41 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 12.41, "10th_percentile": 12.41, "90th_percentile": 12.41, "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 $12.41 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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3.66, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.66, "10th_percentile": 3.66, "90th_percentile": 3.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 9.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 9.31, "10th_percentile": 9.31, "90th_percentile": 9.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12.41, "10th_percentile": 12.41, "90th_percentile": 12.41, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.41, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.41, "10th_percentile": 12.41, "90th_percentile": 12.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 6.21, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 6.21, "10th_percentile": 6.21, "90th_percentile": 6.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 8.69, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 8.69, "10th_percentile": 8.69, "90th_percentile": 8.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 9.06, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 9.06, "10th_percentile": 9.06, "90th_percentile": 9.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 6.54, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.54, "10th_percentile": 6.54, "90th_percentile": 6.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 3.77, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 3.77, "10th_percentile": 3.77, "90th_percentile": 3.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 7.82, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $7.82 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 7.82, "10th_percentile": 7.82, "90th_percentile": 7.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $7.82 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 3.83, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 7.97, "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": 7.97, "10th_percentile": 7.97, "90th_percentile": 7.97, "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": "NWR UHC CORE", "standard_charge_dollar": 5.88, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 5.88, "10th_percentile": 5.88, "90th_percentile": 5.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "description": "25G ILLUMINATED CURVED LASER PROBE", "code_information": [ { "code": "SUP-165158", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 179.19, "maximum": 928.47, "setting": "outpatient", "gross_charge": 928.47, "discounted_cash": 649.93, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 928.47, "10th_percentile": 928.47, "90th_percentile": 928.47, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 928.47, "10th_percentile": 928.47, "90th_percentile": 928.47, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 928.47, "10th_percentile": 928.47, "90th_percentile": 928.47, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 361.64, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 361.64, "10th_percentile": 361.64, "90th_percentile": 361.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 361.64, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 361.64, "10th_percentile": 361.64, "90th_percentile": 361.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 331.28, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 331.28, "10th_percentile": 331.28, "90th_percentile": 331.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 331.28, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 331.28, "10th_percentile": 331.28, "90th_percentile": 331.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 260.81, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 260.81, "10th_percentile": 260.81, "90th_percentile": 260.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 260.81, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 260.81, "10th_percentile": 260.81, "90th_percentile": 260.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 452.16, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 452.16, "10th_percentile": 452.16, "90th_percentile": 452.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 179.19, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 179.19, "10th_percentile": 179.19, "90th_percentile": 179.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 487.45, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 487.45, "10th_percentile": 487.45, "90th_percentile": 487.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 329.61, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 329.61, "10th_percentile": 329.61, "90th_percentile": 329.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 319.39, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 319.39, "10th_percentile": 319.39, "90th_percentile": 319.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 493.95, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 493.95, "10th_percentile": 493.95, "90th_percentile": 493.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 440.09, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 440.09, "10th_percentile": 440.09, "90th_percentile": 440.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 281.79, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 281.79, "10th_percentile": 281.79, "90th_percentile": 281.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 596.36, "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": 596.36, "10th_percentile": 596.36, "90th_percentile": 596.36, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 182.91, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 182.91, "10th_percentile": 182.91, "90th_percentile": 182.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 742.78, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 742.78, "10th_percentile": 742.78, "90th_percentile": 742.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 489.3, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 489.3, "10th_percentile": 489.3, "90th_percentile": 489.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 928.47, "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 $928.47 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 928.47, "10th_percentile": 928.47, "90th_percentile": 928.47, "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 $928.47 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 584.94, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $584.94 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 584.94, "10th_percentile": 584.94, "90th_percentile": 584.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $584.94 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 273.81, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 273.81, "10th_percentile": 273.81, "90th_percentile": 273.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 696.35, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 696.35, "10th_percentile": 696.35, "90th_percentile": 696.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 649.93, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 649.93, "10th_percentile": 649.93, "90th_percentile": 649.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 677.78, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 677.78, "10th_percentile": 677.78, "90th_percentile": 677.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 286.9, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 286.9, "10th_percentile": 286.9, "90th_percentile": 286.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 928.47, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 928.47, "10th_percentile": 928.47, "90th_percentile": 928.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 464.24, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 464.24, "10th_percentile": 464.24, "90th_percentile": 464.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" } ] } ] }, { "description": "25G RETROBULBAR NEEDLE", "code_information": [ { "code": "SUP-348208", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 1.66, "maximum": 8.59, "setting": "outpatient", "gross_charge": 8.59, "discounted_cash": 6.01, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.59, "10th_percentile": 8.59, "90th_percentile": 8.59, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.59, "10th_percentile": 8.59, "90th_percentile": 8.59, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.59, "10th_percentile": 8.59, "90th_percentile": 8.59, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 3.35, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.35, "10th_percentile": 3.35, "90th_percentile": 3.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 3.35, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.35, "10th_percentile": 3.35, "90th_percentile": 3.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 3.06, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 3.06, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2.41, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.41, "10th_percentile": 2.41, "90th_percentile": 2.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.41, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.41, "10th_percentile": 2.41, "90th_percentile": 2.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 1.66, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1.66, "10th_percentile": 1.66, "90th_percentile": 1.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 4.51, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.51, "10th_percentile": 4.51, "90th_percentile": 4.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 3.05, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 3.05, "10th_percentile": 3.05, "90th_percentile": 3.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 2.95, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 2.95, "10th_percentile": 2.95, "90th_percentile": 2.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 4.57, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 4.57, "10th_percentile": 4.57, "90th_percentile": 4.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 4.07, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 4.07, "10th_percentile": 4.07, "90th_percentile": 4.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 2.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 2.61, "10th_percentile": 2.61, "90th_percentile": 2.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 5.52, "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": 5.52, "10th_percentile": 5.52, "90th_percentile": 5.52, "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": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 1.69, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.69, "10th_percentile": 1.69, "90th_percentile": 1.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 6.87, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 6.87, "10th_percentile": 6.87, "90th_percentile": 6.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 4.53, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.53, "10th_percentile": 4.53, "90th_percentile": 4.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 8.59, "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 $8.59 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8.59, "10th_percentile": 8.59, "90th_percentile": 8.59, "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 $8.59 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 5.41, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $5.41 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 5.41, "10th_percentile": 5.41, "90th_percentile": 5.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $5.41 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.53, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.53, "10th_percentile": 2.53, "90th_percentile": 2.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 6.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 6.44, "10th_percentile": 6.44, "90th_percentile": 6.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 6.01, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 6.01, "10th_percentile": 6.01, "90th_percentile": 6.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 6.27, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 6.27, "10th_percentile": 6.27, "90th_percentile": 6.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 2.65, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.65, "10th_percentile": 2.65, "90th_percentile": 2.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 8.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8.59, "10th_percentile": 8.59, "90th_percentile": 8.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 4.3, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 4.3, "10th_percentile": 4.3, "90th_percentile": 4.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 4.18, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.18, "10th_percentile": 4.18, "90th_percentile": 4.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "25MM X10 CROSSLINK FIXED", "code_information": [ { "code": "SUP-106299", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 314.81, "maximum": 1631.15, "setting": "outpatient", "gross_charge": 1631.15, "discounted_cash": 1141.8, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 314.81, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 476.3, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 476.3, "10th_percentile": 476.3, "90th_percentile": 476.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 476.3, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 476.3, "10th_percentile": 476.3, "90th_percentile": 476.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 581.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 581.99, "10th_percentile": 581.99, "90th_percentile": 581.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 561.12, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 561.12, "10th_percentile": 561.12, "90th_percentile": 561.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 579.06, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 579.06, "10th_percentile": 579.06, "90th_percentile": 579.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 859.62, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 504.03, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,631.15 @ 12.5% = $203.89 due to $0.00 Claim Price", "median_amount": 203.89, "10th_percentile": 203.89, "90th_percentile": 203.89, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,631.15 @ 12.5% = $203.89 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 552.96, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 552.96, "10th_percentile": 552.96, "90th_percentile": 552.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 552.96, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 552.96, "10th_percentile": 552.96, "90th_percentile": 552.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 581.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 581.99, "10th_percentile": 581.99, "90th_percentile": 581.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1141.81, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1141.81, "10th_percentile": 1141.81, "90th_percentile": 1141.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 815.58, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 815.58, "10th_percentile": 815.58, "90th_percentile": 815.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1223.36, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1223.36, "10th_percentile": 1223.36, "90th_percentile": 1223.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1190.74, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1190.74, "10th_percentile": 1190.74, "90th_percentile": 1190.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 867.77, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 867.77, "10th_percentile": 867.77, "90th_percentile": 867.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1304.92, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1304.92, "10th_percentile": 1304.92, "90th_percentile": 1304.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1027.62, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,027.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1027.62, "10th_percentile": 1027.62, "90th_percentile": 1027.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,027.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1631.15, "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 $1,631.15 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "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 $1,631.15 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 495.05, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 495.05, "10th_percentile": 495.05, "90th_percentile": 495.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 773.17, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 773.17, "10th_percentile": 773.17, "90th_percentile": 773.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 321.34, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 321.34, "10th_percentile": 321.34, "90th_percentile": 321.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 1047.69, "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": 1047.69, "10th_percentile": 1047.69, "90th_percentile": 1047.69, "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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1631.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "2MM MATCHSTICK BURR", "code_information": [ { "code": "SUP-162182", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 100.66, "maximum": 521.58, "setting": "outpatient", "gross_charge": 521.58, "discounted_cash": 365.11, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 521.58, "10th_percentile": 521.58, "90th_percentile": 521.58, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 521.58, "10th_percentile": 521.58, "90th_percentile": 521.58, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 521.58, "10th_percentile": 521.58, "90th_percentile": 521.58, "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": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 146.51, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 146.51, "10th_percentile": 146.51, "90th_percentile": 146.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 146.51, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 146.51, "10th_percentile": 146.51, "90th_percentile": 146.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 203.16, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 203.16, "10th_percentile": 203.16, "90th_percentile": 203.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 203.16, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 203.16, "10th_percentile": 203.16, "90th_percentile": 203.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 186.1, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 186.1, "10th_percentile": 186.1, "90th_percentile": 186.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 186.1, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 186.1, "10th_percentile": 186.1, "90th_percentile": 186.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 185.16, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 185.16, "10th_percentile": 185.16, "90th_percentile": 185.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 179.42, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 179.42, "10th_percentile": 179.42, "90th_percentile": 179.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 254.01, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 254.01, "10th_percentile": 254.01, "90th_percentile": 254.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 100.66, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 100.66, "10th_percentile": 100.66, "90th_percentile": 100.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 273.83, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 273.83, "10th_percentile": 273.83, "90th_percentile": 273.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 521.58, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 521.58, "10th_percentile": 521.58, "90th_percentile": 521.58, "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 153.81, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 153.81, "10th_percentile": 153.81, "90th_percentile": 153.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 260.79, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 260.79, "10th_percentile": 260.79, "90th_percentile": 260.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 365.11, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 365.11, "10th_percentile": 365.11, "90th_percentile": 365.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 380.75, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 380.75, "10th_percentile": 380.75, "90th_percentile": 380.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 274.87, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 274.87, "10th_percentile": 274.87, "90th_percentile": 274.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 158.3, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 158.3, "10th_percentile": 158.3, "90th_percentile": 158.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 328.6, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $328.60 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 328.6, "10th_percentile": 328.6, "90th_percentile": 328.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $328.60 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 521.58, "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 $521.58 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 521.58, "10th_percentile": 521.58, "90th_percentile": 521.58, "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 $521.58 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 102.75, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.75, "10th_percentile": 102.75, "90th_percentile": 102.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 417.26, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 417.26, "10th_percentile": 417.26, "90th_percentile": 417.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 161.17, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 161.17, "10th_percentile": 161.17, "90th_percentile": 161.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 391.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 391.19, "10th_percentile": 391.19, "90th_percentile": 391.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 277.48, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 277.48, "10th_percentile": 277.48, "90th_percentile": 277.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 335.01, "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": 335.01, "10th_percentile": 335.01, "90th_percentile": 335.01, "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": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 247.23, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 247.23, "10th_percentile": 247.23, "90th_percentile": 247.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "description": "3.0MM X 170MM THREADED PIN", "code_information": [ { "code": "SUP-345128", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 41.42, "maximum": 214.63, "setting": "outpatient", "gross_charge": 214.63, "discounted_cash": 150.24, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 41.42, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 113.11, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 66.32, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $214.63 @ 12.5% = $26.83 due to $0.00 Claim Price", "median_amount": 26.83, "10th_percentile": 26.83, "90th_percentile": 26.83, "count": "0", "methodology": "other", "additional_payer_notes": "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: $214.63 @ 12.5% = $26.83 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 214.63, "10th_percentile": 214.63, "90th_percentile": 214.63, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 214.63, "10th_percentile": 214.63, "90th_percentile": 214.63, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 62.67, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.67, "10th_percentile": 62.67, "90th_percentile": 62.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 62.67, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.67, "10th_percentile": 62.67, "90th_percentile": 62.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 72.76, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.76, "10th_percentile": 72.76, "90th_percentile": 72.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 72.76, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.76, "10th_percentile": 72.76, "90th_percentile": 72.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 76.58, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.58, "10th_percentile": 76.58, "90th_percentile": 76.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 76.58, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.58, "10th_percentile": 76.58, "90th_percentile": 76.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 150.24, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 150.24, "10th_percentile": 150.24, "90th_percentile": 150.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 107.32, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 107.32, "10th_percentile": 107.32, "90th_percentile": 107.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 76.19, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 76.19, "10th_percentile": 76.19, "90th_percentile": 76.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 160.97, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 160.97, "10th_percentile": 160.97, "90th_percentile": 160.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 156.68, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 156.68, "10th_percentile": 156.68, "90th_percentile": 156.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 114.18, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 114.18, "10th_percentile": 114.18, "90th_percentile": 114.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 171.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 171.7, "10th_percentile": 171.7, "90th_percentile": 171.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 135.22, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $135.22 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 135.22, "10th_percentile": 135.22, "90th_percentile": 135.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $135.22 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 214.63, "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 $214.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 214.63, "10th_percentile": 214.63, "90th_percentile": 214.63, "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 $214.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 65.14, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% 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; 30.35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 73.83, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 73.83, "10th_percentile": 73.83, "90th_percentile": 73.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 101.73, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 101.73, "10th_percentile": 101.73, "90th_percentile": 101.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 42.28, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.28, "10th_percentile": 42.28, "90th_percentile": 42.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 137.86, "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": 137.86, "10th_percentile": 137.86, "90th_percentile": 137.86, "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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 214.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 214.63, "10th_percentile": 214.63, "90th_percentile": 214.63, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 102.59, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.59, "10th_percentile": 102.59, "90th_percentile": 102.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 102.59, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.59, "10th_percentile": 102.59, "90th_percentile": 102.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 102.59, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.59, "10th_percentile": 102.59, "90th_percentile": 102.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "3.2MM TITANIUM ROD 240MM", "code_information": [ { "code": "SUP-58639", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 95.51, "maximum": 494.89, "setting": "outpatient", "gross_charge": 494.89, "discounted_cash": 346.42, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 95.51, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 152.92, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $494.89 @ 12.5% = $61.86 due to $0.00 Claim Price", "median_amount": 61.86, "10th_percentile": 61.86, "90th_percentile": 61.86, "count": "0", "methodology": "other", "additional_payer_notes": "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: $494.89 @ 12.5% = $61.86 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 494.89, "10th_percentile": 494.89, "90th_percentile": 494.89, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 494.89, "10th_percentile": 494.89, "90th_percentile": 494.89, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 144.51, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 144.51, "10th_percentile": 144.51, "90th_percentile": 144.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 144.51, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 144.51, "10th_percentile": 144.51, "90th_percentile": 144.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 167.77, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 167.77, "10th_percentile": 167.77, "90th_percentile": 167.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 167.77, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 167.77, "10th_percentile": 167.77, "90th_percentile": 167.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 176.58, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.58, "10th_percentile": 176.58, "90th_percentile": 176.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 176.58, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.58, "10th_percentile": 176.58, "90th_percentile": 176.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 346.42, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 346.42, "10th_percentile": 346.42, "90th_percentile": 346.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 175.69, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 175.69, "10th_percentile": 175.69, "90th_percentile": 175.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 371.17, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 371.17, "10th_percentile": 371.17, "90th_percentile": 371.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 263.28, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 263.28, "10th_percentile": 263.28, "90th_percentile": 263.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 395.91, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 395.91, "10th_percentile": 395.91, "90th_percentile": 395.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 494.89, "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 $494.89 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 494.89, "10th_percentile": 494.89, "90th_percentile": 494.89, "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 $494.89 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 170.24, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 170.24, "10th_percentile": 170.24, "90th_percentile": 170.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 97.49, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 97.49, "10th_percentile": 97.49, "90th_percentile": 97.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 236.56, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 236.56, "10th_percentile": 236.56, "90th_percentile": 236.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 236.56, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 236.56, "10th_percentile": 236.56, "90th_percentile": 236.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 236.56, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 236.56, "10th_percentile": 236.56, "90th_percentile": 236.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 260.81, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 247.45, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 247.45, "10th_percentile": 247.45, "90th_percentile": 247.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 361.27, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 361.27, "10th_percentile": 361.27, "90th_percentile": 361.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 150.2, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 150.2, "10th_percentile": 150.2, "90th_percentile": 150.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 311.78, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $311.78 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 311.78, "10th_percentile": 311.78, "90th_percentile": 311.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $311.78 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 494.89, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 494.89, "10th_percentile": 494.89, "90th_percentile": 494.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 317.87, "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": 317.87, "10th_percentile": 317.87, "90th_percentile": 317.87, "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": "NWR UHC CORE", "standard_charge_dollar": 234.58, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 234.58, "10th_percentile": 234.58, "90th_percentile": 234.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "description": "30-34MM X10 CROSSLINK MULTI", "code_information": [ { "code": "SUP-115463", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 314.81, "maximum": 1631.15, "setting": "outpatient", "gross_charge": 1631.15, "discounted_cash": 1141.8, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 314.81, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 859.62, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 504.03, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,631.15 @ 12.5% = $203.89 due to $0.00 Claim Price", "median_amount": 203.89, "10th_percentile": 203.89, "90th_percentile": 203.89, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,631.15 @ 12.5% = $203.89 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 476.3, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 476.3, "10th_percentile": 476.3, "90th_percentile": 476.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 476.3, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 476.3, "10th_percentile": 476.3, "90th_percentile": 476.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 552.96, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 552.96, "10th_percentile": 552.96, "90th_percentile": 552.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 552.96, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 552.96, "10th_percentile": 552.96, "90th_percentile": 552.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 581.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 581.99, "10th_percentile": 581.99, "90th_percentile": 581.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 581.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 581.99, "10th_percentile": 581.99, "90th_percentile": 581.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1141.81, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1141.81, "10th_percentile": 1141.81, "90th_percentile": 1141.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 815.58, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 815.58, "10th_percentile": 815.58, "90th_percentile": 815.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 579.06, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 579.06, "10th_percentile": 579.06, "90th_percentile": 579.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1223.36, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1223.36, "10th_percentile": 1223.36, "90th_percentile": 1223.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1190.74, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1190.74, "10th_percentile": 1190.74, "90th_percentile": 1190.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 867.77, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 867.77, "10th_percentile": 867.77, "90th_percentile": 867.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1304.92, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1304.92, "10th_percentile": 1304.92, "90th_percentile": 1304.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1027.62, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,027.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1027.62, "10th_percentile": 1027.62, "90th_percentile": 1027.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,027.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1631.15, "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 $1,631.15 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "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 $1,631.15 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 495.05, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 495.05, "10th_percentile": 495.05, "90th_percentile": 495.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 561.12, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 561.12, "10th_percentile": 561.12, "90th_percentile": 561.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 773.17, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 773.17, "10th_percentile": 773.17, "90th_percentile": 773.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 321.34, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 321.34, "10th_percentile": 321.34, "90th_percentile": 321.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 1047.69, "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": 1047.69, "10th_percentile": 1047.69, "90th_percentile": 1047.69, "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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1631.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "3D LONG SCREW 7.5MM X 55MM TI", "code_information": [ { "code": "SUP-71523", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 300.31, "maximum": 1556.03, "setting": "outpatient", "gross_charge": 1556.03, "discounted_cash": 1089.22, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 300.31, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 820.03, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 480.81, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,556.03 @ 12.5% = $194.50 due to $0.00 Claim Price", "median_amount": 194.5, "10th_percentile": 194.5, "90th_percentile": 194.5, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,556.03 @ 12.5% = $194.50 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1556.03, "10th_percentile": 1556.03, "90th_percentile": 1556.03, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1556.03, "10th_percentile": 1556.03, "90th_percentile": 1556.03, "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": "NWR BCBS PPO", "standard_charge_dollar": 527.49, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 527.49, "10th_percentile": 527.49, "90th_percentile": 527.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 527.49, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 527.49, "10th_percentile": 527.49, "90th_percentile": 527.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 454.36, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 454.36, "10th_percentile": 454.36, "90th_percentile": 454.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 454.36, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 454.36, "10th_percentile": 454.36, "90th_percentile": 454.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 555.19, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 555.19, "10th_percentile": 555.19, "90th_percentile": 555.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 555.19, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 555.19, "10th_percentile": 555.19, "90th_percentile": 555.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 552.39, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 552.39, "10th_percentile": 552.39, "90th_percentile": 552.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 827.81, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 827.81, "10th_percentile": 827.81, "90th_percentile": 827.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 535.27, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 535.27, "10th_percentile": 535.27, "90th_percentile": 535.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1089.22, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1089.22, "10th_percentile": 1089.22, "90th_percentile": 1089.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 778.02, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 778.02, "10th_percentile": 778.02, "90th_percentile": 778.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1135.9, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1135.9, "10th_percentile": 1135.9, "90th_percentile": 1135.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 472.26, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 472.26, "10th_percentile": 472.26, "90th_percentile": 472.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1556.03, "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 $1,556.03 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1556.03, "10th_percentile": 1556.03, "90th_percentile": 1556.03, "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 $1,556.03 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 980.3, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $980.30 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 980.3, "10th_percentile": 980.3, "90th_percentile": 980.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $980.30 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1556.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1556.03, "10th_percentile": 1556.03, "90th_percentile": 1556.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1167.02, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1167.02, "10th_percentile": 1167.02, "90th_percentile": 1167.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 306.54, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 306.54, "10th_percentile": 306.54, "90th_percentile": 306.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 999.44, "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": 999.44, "10th_percentile": 999.44, "90th_percentile": 999.44, "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": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1244.82, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1244.82, "10th_percentile": 1244.82, "90th_percentile": 1244.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 737.56, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 737.56, "10th_percentile": 737.56, "90th_percentile": 737.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 743.78, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 743.78, "10th_percentile": 743.78, "90th_percentile": 743.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 743.78, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 743.78, "10th_percentile": 743.78, "90th_percentile": 743.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 743.78, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 743.78, "10th_percentile": 743.78, "90th_percentile": 743.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "3D THREAD SCRW 5.5MMX45 TI", "code_information": [ { "code": "SUP-70555", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 328.9, "maximum": 1704.12, "setting": "outpatient", "gross_charge": 1704.12, "discounted_cash": 1192.88, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 328.9, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 898.07, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 526.57, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,704.12 @ 12.5% = $213.02 due to $0.00 Claim Price", "median_amount": 213.02, "10th_percentile": 213.02, "90th_percentile": 213.02, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,704.12 @ 12.5% = $213.02 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1704.12, "10th_percentile": 1704.12, "90th_percentile": 1704.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1704.12, "10th_percentile": 1704.12, "90th_percentile": 1704.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 497.6, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 497.6, "10th_percentile": 497.6, "90th_percentile": 497.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 497.6, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 497.6, "10th_percentile": 497.6, "90th_percentile": 497.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 577.7, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 577.7, "10th_percentile": 577.7, "90th_percentile": 577.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 577.7, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 577.7, "10th_percentile": 577.7, "90th_percentile": 577.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 608.03, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 608.03, "10th_percentile": 608.03, "90th_percentile": 608.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 608.03, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 608.03, "10th_percentile": 608.03, "90th_percentile": 608.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1192.88, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1192.88, "10th_percentile": 1192.88, "90th_percentile": 1192.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 852.06, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 852.06, "10th_percentile": 852.06, "90th_percentile": 852.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 604.96, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 604.96, "10th_percentile": 604.96, "90th_percentile": 604.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1278.09, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1278.09, "10th_percentile": 1278.09, "90th_percentile": 1278.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1244.01, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1244.01, "10th_percentile": 1244.01, "90th_percentile": 1244.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 906.59, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 906.59, "10th_percentile": 906.59, "90th_percentile": 906.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1363.3, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1363.3, "10th_percentile": 1363.3, "90th_percentile": 1363.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1073.6, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,073.60 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1073.6, "10th_percentile": 1073.6, "90th_percentile": 1073.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,073.60 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1704.12, "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 $1,704.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1704.12, "10th_percentile": 1704.12, "90th_percentile": 1704.12, "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 $1,704.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 517.2, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 517.2, "10th_percentile": 517.2, "90th_percentile": 517.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 586.22, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 586.22, "10th_percentile": 586.22, "90th_percentile": 586.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 807.75, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 807.75, "10th_percentile": 807.75, "90th_percentile": 807.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 335.71, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 335.71, "10th_percentile": 335.71, "90th_percentile": 335.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 1094.56, "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": 1094.56, "10th_percentile": 1094.56, "90th_percentile": 1094.56, "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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1704.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1704.12, "10th_percentile": 1704.12, "90th_percentile": 1704.12, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 814.57, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 814.57, "10th_percentile": 814.57, "90th_percentile": 814.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 814.57, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 814.57, "10th_percentile": 814.57, "90th_percentile": 814.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 814.57, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 814.57, "10th_percentile": 814.57, "90th_percentile": 814.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "3D THREAD SCRW 7.5MMX45 TI", "code_information": [ { "code": "SUP-70556", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 328.9, "maximum": 1704.12, "setting": "outpatient", "gross_charge": 1704.12, "discounted_cash": 1192.88, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 898.07, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 526.57, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 328.9, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,704.12 @ 12.5% = $213.02 due to $0.00 Claim Price", "median_amount": 213.02, "10th_percentile": 213.02, "90th_percentile": 213.02, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,704.12 @ 12.5% = $213.02 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1704.12, "10th_percentile": 1704.12, "90th_percentile": 1704.12, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1704.12, "10th_percentile": 1704.12, "90th_percentile": 1704.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 577.7, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 577.7, "10th_percentile": 577.7, "90th_percentile": 577.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 577.7, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 577.7, "10th_percentile": 577.7, "90th_percentile": 577.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 497.6, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 497.6, "10th_percentile": 497.6, "90th_percentile": 497.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 497.6, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 497.6, "10th_percentile": 497.6, "90th_percentile": 497.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 608.03, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 608.03, "10th_percentile": 608.03, "90th_percentile": 608.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 608.03, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 608.03, "10th_percentile": 608.03, "90th_percentile": 608.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 586.22, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 586.22, "10th_percentile": 586.22, "90th_percentile": 586.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 852.06, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 852.06, "10th_percentile": 852.06, "90th_percentile": 852.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1363.3, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1363.3, "10th_percentile": 1363.3, "90th_percentile": 1363.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 604.96, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 604.96, "10th_percentile": 604.96, "90th_percentile": 604.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 335.71, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 335.71, "10th_percentile": 335.71, "90th_percentile": 335.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1278.09, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1278.09, "10th_percentile": 1278.09, "90th_percentile": 1278.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 906.59, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 906.59, "10th_percentile": 906.59, "90th_percentile": 906.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 1094.56, "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": 1094.56, "10th_percentile": 1094.56, "90th_percentile": 1094.56, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1704.12, "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 $1,704.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1704.12, "10th_percentile": 1704.12, "90th_percentile": 1704.12, "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 $1,704.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1073.6, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,073.60 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1073.6, "10th_percentile": 1073.6, "90th_percentile": 1073.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,073.60 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1192.88, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1192.88, "10th_percentile": 1192.88, "90th_percentile": 1192.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1704.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1704.12, "10th_percentile": 1704.12, "90th_percentile": 1704.12, "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": "NWR HFN PPO", "standard_charge_dollar": 1244.01, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1244.01, "10th_percentile": 1244.01, "90th_percentile": 1244.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 807.75, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 807.75, "10th_percentile": 807.75, "90th_percentile": 807.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 517.2, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 517.2, "10th_percentile": 517.2, "90th_percentile": 517.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 814.57, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 814.57, "10th_percentile": 814.57, "90th_percentile": 814.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 814.57, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 814.57, "10th_percentile": 814.57, "90th_percentile": 814.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 814.57, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 814.57, "10th_percentile": 814.57, "90th_percentile": 814.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "4.0MM CANN SCRW-LONG THRD 52MM", "code_information": [ { "code": "SUP-377137", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 100.54, "maximum": 520.94, "setting": "outpatient", "gross_charge": 520.94, "discounted_cash": 364.66, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 274.54, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 160.97, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 100.54, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $520.94 @ 12.5% = $65.12 due to $0.00 Claim Price", "median_amount": 65.12, "10th_percentile": 65.12, "90th_percentile": 65.12, "count": "0", "methodology": "other", "additional_payer_notes": "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: $520.94 @ 12.5% = $65.12 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 520.94, "10th_percentile": 520.94, "90th_percentile": 520.94, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 520.94, "10th_percentile": 520.94, "90th_percentile": 520.94, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 176.6, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.6, "10th_percentile": 176.6, "90th_percentile": 176.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 176.6, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.6, "10th_percentile": 176.6, "90th_percentile": 176.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 152.11, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 152.11, "10th_percentile": 152.11, "90th_percentile": 152.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 152.11, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 152.11, "10th_percentile": 152.11, "90th_percentile": 152.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 185.87, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 185.87, "10th_percentile": 185.87, "90th_percentile": 185.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 185.87, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 185.87, "10th_percentile": 185.87, "90th_percentile": 185.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 179.2, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 179.2, "10th_percentile": 179.2, "90th_percentile": 179.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 260.47, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 260.47, "10th_percentile": 260.47, "90th_percentile": 260.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 416.75, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 416.75, "10th_percentile": 416.75, "90th_percentile": 416.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 184.93, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 184.93, "10th_percentile": 184.93, "90th_percentile": 184.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 102.63, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.63, "10th_percentile": 102.63, "90th_percentile": 102.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 390.71, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 390.71, "10th_percentile": 390.71, "90th_percentile": 390.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 277.14, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 277.14, "10th_percentile": 277.14, "90th_percentile": 277.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 334.6, "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": 334.6, "10th_percentile": 334.6, "90th_percentile": 334.6, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 520.94, "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 $520.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 520.94, "10th_percentile": 520.94, "90th_percentile": 520.94, "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 $520.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 328.19, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $328.19 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 328.19, "10th_percentile": 328.19, "90th_percentile": 328.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $328.19 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 364.66, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 364.66, "10th_percentile": 364.66, "90th_percentile": 364.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 520.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 520.94, "10th_percentile": 520.94, "90th_percentile": 520.94, "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": "NWR HFN PPO", "standard_charge_dollar": 380.29, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 380.29, "10th_percentile": 380.29, "90th_percentile": 380.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 246.93, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 246.93, "10th_percentile": 246.93, "90th_percentile": 246.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 158.11, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 158.11, "10th_percentile": 158.11, "90th_percentile": 158.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 249.01, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 249.01, "10th_percentile": 249.01, "90th_percentile": 249.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 249.01, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 249.01, "10th_percentile": 249.01, "90th_percentile": 249.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 249.01, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 249.01, "10th_percentile": 249.01, "90th_percentile": 249.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "4.0MM CANN SCRW-LONG THRD 64MM", "code_information": [ { "code": "SUP-377140", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 100.54, "maximum": 520.94, "setting": "outpatient", "gross_charge": 520.94, "discounted_cash": 364.66, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 100.54, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 274.54, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 160.97, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $520.94 @ 12.5% = $65.12 due to $0.00 Claim Price", "median_amount": 65.12, "10th_percentile": 65.12, "90th_percentile": 65.12, "count": "0", "methodology": "other", "additional_payer_notes": "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: $520.94 @ 12.5% = $65.12 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 520.94, "10th_percentile": 520.94, "90th_percentile": 520.94, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 520.94, "10th_percentile": 520.94, "90th_percentile": 520.94, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 152.11, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 152.11, "10th_percentile": 152.11, "90th_percentile": 152.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 152.11, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 152.11, "10th_percentile": 152.11, "90th_percentile": 152.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 176.6, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.6, "10th_percentile": 176.6, "90th_percentile": 176.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 176.6, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.6, "10th_percentile": 176.6, "90th_percentile": 176.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 185.87, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 185.87, "10th_percentile": 185.87, "90th_percentile": 185.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 185.87, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 185.87, "10th_percentile": 185.87, "90th_percentile": 185.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 364.66, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 364.66, "10th_percentile": 364.66, "90th_percentile": 364.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 260.47, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 260.47, "10th_percentile": 260.47, "90th_percentile": 260.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 184.93, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 184.93, "10th_percentile": 184.93, "90th_percentile": 184.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 390.71, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 390.71, "10th_percentile": 390.71, "90th_percentile": 390.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 380.29, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 380.29, "10th_percentile": 380.29, "90th_percentile": 380.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 277.14, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 277.14, "10th_percentile": 277.14, "90th_percentile": 277.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 416.75, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 416.75, "10th_percentile": 416.75, "90th_percentile": 416.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 328.19, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $328.19 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 328.19, "10th_percentile": 328.19, "90th_percentile": 328.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $328.19 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 520.94, "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 $520.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 520.94, "10th_percentile": 520.94, "90th_percentile": 520.94, "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 $520.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 158.11, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 158.11, "10th_percentile": 158.11, "90th_percentile": 158.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 179.2, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 179.2, "10th_percentile": 179.2, "90th_percentile": 179.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 246.93, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 246.93, "10th_percentile": 246.93, "90th_percentile": 246.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 102.63, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.63, "10th_percentile": 102.63, "90th_percentile": 102.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 334.6, "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": 334.6, "10th_percentile": 334.6, "90th_percentile": 334.6, "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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 520.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 520.94, "10th_percentile": 520.94, "90th_percentile": 520.94, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 249.01, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 249.01, "10th_percentile": 249.01, "90th_percentile": 249.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 249.01, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 249.01, "10th_percentile": 249.01, "90th_percentile": 249.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 249.01, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 249.01, "10th_percentile": 249.01, "90th_percentile": 249.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "4.5 X 15 SELF-TAP FIX SCREW", "code_information": [ { "code": "SUP-107669", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 78.7, "maximum": 407.79, "setting": "outpatient", "gross_charge": 407.79, "discounted_cash": 285.45, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 78.7, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 214.91, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 126.01, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $407.79 @ 12.5% = $50.97 due to $0.00 Claim Price", "median_amount": 50.97, "10th_percentile": 50.97, "90th_percentile": 50.97, "count": "0", "methodology": "other", "additional_payer_notes": "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: $407.79 @ 12.5% = $50.97 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 407.79, "10th_percentile": 407.79, "90th_percentile": 407.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 407.79, "10th_percentile": 407.79, "90th_percentile": 407.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 119.07, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 119.07, "10th_percentile": 119.07, "90th_percentile": 119.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 119.07, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 119.07, "10th_percentile": 119.07, "90th_percentile": 119.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 138.24, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 138.24, "10th_percentile": 138.24, "90th_percentile": 138.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 138.24, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 138.24, "10th_percentile": 138.24, "90th_percentile": 138.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 145.5, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 145.5, "10th_percentile": 145.5, "90th_percentile": 145.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 145.5, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 145.5, "10th_percentile": 145.5, "90th_percentile": 145.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 285.45, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 285.45, "10th_percentile": 285.45, "90th_percentile": 285.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 203.9, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 203.9, "10th_percentile": 203.9, "90th_percentile": 203.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 144.77, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 144.77, "10th_percentile": 144.77, "90th_percentile": 144.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 305.84, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 305.84, "10th_percentile": 305.84, "90th_percentile": 305.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 297.69, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 297.69, "10th_percentile": 297.69, "90th_percentile": 297.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 216.94, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 216.94, "10th_percentile": 216.94, "90th_percentile": 216.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 326.23, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 326.23, "10th_percentile": 326.23, "90th_percentile": 326.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 256.91, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $256.91 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 256.91, "10th_percentile": 256.91, "90th_percentile": 256.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $256.91 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 407.79, "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 $407.79 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 407.79, "10th_percentile": 407.79, "90th_percentile": 407.79, "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 $407.79 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 123.76, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 123.76, "10th_percentile": 123.76, "90th_percentile": 123.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 140.28, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 140.28, "10th_percentile": 140.28, "90th_percentile": 140.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 193.29, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 193.29, "10th_percentile": 193.29, "90th_percentile": 193.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 80.33, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 80.33, "10th_percentile": 80.33, "90th_percentile": 80.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 261.92, "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": 261.92, "10th_percentile": 261.92, "90th_percentile": 261.92, "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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 407.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 407.79, "10th_percentile": 407.79, "90th_percentile": 407.79, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 194.92, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 194.92, "10th_percentile": 194.92, "90th_percentile": 194.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 194.92, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 194.92, "10th_percentile": 194.92, "90th_percentile": 194.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 194.92, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 194.92, "10th_percentile": 194.92, "90th_percentile": 194.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "4.5X15MM PK PAPYRUS COVERED STENT", "code_information": [ { "code": "SUP-350650", "type": "CDM" }, { "code": "C1874", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 2236.82, "maximum": 11589.75, "setting": "outpatient", "gross_charge": 11589.75, "discounted_cash": 8112.82, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 4114.36, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 8780.07, "10th_percentile": 8780.07, "90th_percentile": 8780.07, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5539.9, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5539.9, "10th_percentile": 5539.9, "90th_percentile": 5539.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5539.9, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5539.9, "10th_percentile": 5539.9, "90th_percentile": 5539.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5539.9, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5539.9, "10th_percentile": 5539.9, "90th_percentile": 5539.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 3928.93, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3928.93, "10th_percentile": 3928.93, "90th_percentile": 3928.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 3928.93, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3928.93, "10th_percentile": 3928.93, "90th_percentile": 3928.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 3384.21, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3384.21, "10th_percentile": 3384.21, "90th_percentile": 3384.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 3384.21, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3384.21, "10th_percentile": 3384.21, "90th_percentile": 3384.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 4135.22, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4135.22, "10th_percentile": 4135.22, "90th_percentile": 4135.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 4135.22, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4135.22, "10th_percentile": 4135.22, "90th_percentile": 4135.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 2283.18, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2283.18, "10th_percentile": 2283.18, "90th_percentile": 2283.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 8692.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 8692.31, "10th_percentile": 8692.31, "90th_percentile": 8692.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 8460.52, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 8460.52, "10th_percentile": 8460.52, "90th_percentile": 8460.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 3581.23, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 663.47, "10th_percentile": 663.47, "90th_percentile": 663.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 5794.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 5794.88, "10th_percentile": 5794.88, "90th_percentile": 5794.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 9271.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 9271.8, "10th_percentile": 9271.8, "90th_percentile": 9271.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 3517.49, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 3517.49, "10th_percentile": 3517.49, "90th_percentile": 3517.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 6165.75, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 6165.75, "10th_percentile": 6165.75, "90th_percentile": 6165.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 11589.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 11589.75, "10th_percentile": 11589.75, "90th_percentile": 11589.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 2236.82, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 2236.82, "10th_percentile": 2236.82, "90th_percentile": 2236.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 8112.83, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 8112.83, "10th_percentile": 8112.83, "90th_percentile": 8112.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 3986.87, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 3986.87, "10th_percentile": 3986.87, "90th_percentile": 3986.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 11589.75, "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 $11,589.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 11589.75, "10th_percentile": 11589.75, "90th_percentile": 11589.75, "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 $11,589.75 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11589.75, "10th_percentile": 11589.75, "90th_percentile": 11589.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11589.75, "10th_percentile": 11589.75, "90th_percentile": 11589.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $11,589.75 @ 12.5% = $1,448.72 due to $0.00 Claim Price", "median_amount": 1448.72, "10th_percentile": 1448.72, "90th_percentile": 1448.72, "count": "0", "methodology": "other", "additional_payer_notes": "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: $11,589.75 @ 12.5% = $1,448.72 due to $0.00 Claim Price" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 5493.54, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 5493.54, "10th_percentile": 5493.54, "90th_percentile": 5493.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 6107.8, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6107.8, "10th_percentile": 6107.8, "90th_percentile": 6107.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 7444.1, "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": 7444.1, "10th_percentile": 7444.1, "90th_percentile": 7444.1, "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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 7301.54, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $7,301.54 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 7301.54, "10th_percentile": 7301.54, "90th_percentile": 7301.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $7,301.54 so that total pmt for all claim lines does not exceed 63% of claim billed amount." } ] } ] }, { "description": "5.5MM X 500MM OFFSET SRT COCR RELINE ROD", "code_information": [ { "code": "SUP-165763", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 207.11, "maximum": 1073.13, "setting": "outpatient", "gross_charge": 1073.13, "discounted_cash": 751.19, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 207.11, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1073.13, "10th_percentile": 1073.13, "90th_percentile": 1073.13, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1073.13, "10th_percentile": 1073.13, "90th_percentile": 1073.13, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 313.35, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 313.35, "10th_percentile": 313.35, "90th_percentile": 313.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 313.35, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 313.35, "10th_percentile": 313.35, "90th_percentile": 313.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 363.79, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 363.79, "10th_percentile": 363.79, "90th_percentile": 363.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 363.79, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 363.79, "10th_percentile": 363.79, "90th_percentile": 363.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 382.89, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 382.89, "10th_percentile": 382.89, "90th_percentile": 382.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 382.89, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 382.89, "10th_percentile": 382.89, "90th_percentile": 382.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 380.96, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 380.96, "10th_percentile": 380.96, "90th_percentile": 380.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 858.5, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 858.5, "10th_percentile": 858.5, "90th_percentile": 858.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1073.13, "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 $1,073.13 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1073.13, "10th_percentile": 1073.13, "90th_percentile": 1073.13, "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 $1,073.13 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 369.16, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 369.16, "10th_percentile": 369.16, "90th_percentile": 369.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 512.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 512.96, "10th_percentile": 512.96, "90th_percentile": 512.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 512.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 512.96, "10th_percentile": 512.96, "90th_percentile": 512.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 512.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 512.96, "10th_percentile": 512.96, "90th_percentile": 512.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 565.54, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 331.6, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,073.13 @ 12.5% = $134.14 due to $0.00 Claim Price", "median_amount": 134.14, "10th_percentile": 134.14, "90th_percentile": 134.14, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,073.13 @ 12.5% = $134.14 due to $0.00 Claim Price" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 570.91, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 570.91, "10th_percentile": 570.91, "90th_percentile": 570.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 751.19, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 751.19, "10th_percentile": 751.19, "90th_percentile": 751.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 536.57, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 536.57, "10th_percentile": 536.57, "90th_percentile": 536.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 783.38, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 783.38, "10th_percentile": 783.38, "90th_percentile": 783.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 325.69, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 325.69, "10th_percentile": 325.69, "90th_percentile": 325.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 676.07, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $676.07 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 676.07, "10th_percentile": 676.07, "90th_percentile": 676.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $676.07 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1073.13, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1073.13, "10th_percentile": 1073.13, "90th_percentile": 1073.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 804.85, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 804.85, "10th_percentile": 804.85, "90th_percentile": 804.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 211.41, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 211.41, "10th_percentile": 211.41, "90th_percentile": 211.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 689.27, "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": 689.27, "10th_percentile": 689.27, "90th_percentile": 689.27, "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": "NWR UHC CORE", "standard_charge_dollar": 508.66, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 508.66, "10th_percentile": 508.66, "90th_percentile": 508.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "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": 462.49, "maximum": 2396.31, "setting": "outpatient", "gross_charge": 2396.31, "discounted_cash": 1677.42, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 462.49, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1262.86, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 740.46, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $2,396.31 @ 12.5% = $299.54 due to $0.00 Claim Price", "median_amount": 299.54, "10th_percentile": 299.54, "90th_percentile": 299.54, "count": "0", "methodology": "other", "additional_payer_notes": "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: $2,396.31 @ 12.5% = $299.54 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2396.31, "10th_percentile": 2396.31, "90th_percentile": 2396.31, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2396.31, "10th_percentile": 2396.31, "90th_percentile": 2396.31, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 699.72, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 699.72, "10th_percentile": 699.72, "90th_percentile": 699.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 699.72, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 699.72, "10th_percentile": 699.72, "90th_percentile": 699.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 812.35, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 812.35, "10th_percentile": 812.35, "90th_percentile": 812.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 812.35, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 812.35, "10th_percentile": 812.35, "90th_percentile": 812.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 855.0, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 855.0, "10th_percentile": 855.0, "90th_percentile": 855.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 855.0, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 855.0, "10th_percentile": 855.0, "90th_percentile": 855.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1677.42, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1677.42, "10th_percentile": 1677.42, "90th_percentile": 1677.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1198.16, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1198.16, "10th_percentile": 1198.16, "90th_percentile": 1198.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 850.69, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 850.69, "10th_percentile": 850.69, "90th_percentile": 850.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1797.23, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1797.23, "10th_percentile": 1797.23, "90th_percentile": 1797.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1749.31, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1749.31, "10th_percentile": 1749.31, "90th_percentile": 1749.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1274.84, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1274.84, "10th_percentile": 1274.84, "90th_percentile": 1274.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1917.05, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1917.05, "10th_percentile": 1917.05, "90th_percentile": 1917.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1509.68, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,509.68 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1509.68, "10th_percentile": 1509.68, "90th_percentile": 1509.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,509.68 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2396.31, "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 $2,396.31 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2396.31, "10th_percentile": 2396.31, "90th_percentile": 2396.31, "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 $2,396.31 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 727.28, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 727.28, "10th_percentile": 727.28, "90th_percentile": 727.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 824.33, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 824.33, "10th_percentile": 824.33, "90th_percentile": 824.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 1135.85, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1135.85, "10th_percentile": 1135.85, "90th_percentile": 1135.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 472.07, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 472.07, "10th_percentile": 472.07, "90th_percentile": 472.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 1539.15, "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": 1539.15, "10th_percentile": 1539.15, "90th_percentile": 1539.15, "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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 2396.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2396.31, "10th_percentile": 2396.31, "90th_percentile": 2396.31, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1145.44, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1145.44, "10th_percentile": 1145.44, "90th_percentile": 1145.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1145.44, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1145.44, "10th_percentile": 1145.44, "90th_percentile": 1145.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1145.44, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1145.44, "10th_percentile": 1145.44, "90th_percentile": 1145.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "5Fr Angled Pigtail 145 DxTerity w/Side Holes Diag Catheter", "code_information": [ { "code": "SUP-356649", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 12.43, "maximum": 64.39, "setting": "outpatient", "gross_charge": 64.39, "discounted_cash": 45.07, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 64.39, "10th_percentile": 64.39, "90th_percentile": 64.39, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 64.39, "10th_percentile": 64.39, "90th_percentile": 64.39, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 64.39, "10th_percentile": 64.39, "90th_percentile": 64.39, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 18.09, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.09, "10th_percentile": 18.09, "90th_percentile": 18.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 18.09, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.09, "10th_percentile": 18.09, "90th_percentile": 18.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 22.97, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.97, "10th_percentile": 22.97, "90th_percentile": 22.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 22.97, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.97, "10th_percentile": 22.97, "90th_percentile": 22.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 25.08, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 25.08, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 22.86, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 22.86, "10th_percentile": 22.86, "90th_percentile": 22.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 33.8, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.8, "10th_percentile": 33.8, "90th_percentile": 33.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 22.15, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 22.15, "10th_percentile": 22.15, "90th_percentile": 22.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 31.36, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.36, "10th_percentile": 31.36, "90th_percentile": 31.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 12.43, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 12.43, "10th_percentile": 12.43, "90th_percentile": 12.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 41.36, "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": 41.36, "10th_percentile": 41.36, "90th_percentile": 41.36, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 48.29, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 48.29, "10th_percentile": 48.29, "90th_percentile": 48.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 18.99, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.99, "10th_percentile": 18.99, "90th_percentile": 18.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 19.54, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 19.54, "10th_percentile": 19.54, "90th_percentile": 19.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 30.52, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 30.52, "10th_percentile": 30.52, "90th_percentile": 30.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 47.0, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 47.0, "10th_percentile": 47.0, "90th_percentile": 47.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 34.26, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 34.26, "10th_percentile": 34.26, "90th_percentile": 34.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 40.57, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $40.57 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 40.57, "10th_percentile": 40.57, "90th_percentile": 40.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $40.57 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 64.39, "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 $64.39 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 64.39, "10th_percentile": 64.39, "90th_percentile": 64.39, "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 $64.39 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 64.39, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 64.39, "10th_percentile": 64.39, "90th_percentile": 64.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 12.68, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.68, "10th_percentile": 12.68, "90th_percentile": 12.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 33.93, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.93, "10th_percentile": 33.93, "90th_percentile": 33.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 32.2, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 32.2, "10th_percentile": 32.2, "90th_percentile": 32.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 51.51, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 51.51, "10th_percentile": 51.51, "90th_percentile": 51.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 19.9, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.9, "10th_percentile": 19.9, "90th_percentile": 19.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 45.07, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 45.07, "10th_percentile": 45.07, "90th_percentile": 45.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" } ] } ] }, { "description": "5Fr MPA1 0.038\" x 125cm Diagnostic Catheter", "code_information": [ { "code": "SUP-314423", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 44.74, "maximum": 231.8, "setting": "outpatient", "gross_charge": 231.8, "discounted_cash": 162.26, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 231.8, "10th_percentile": 231.8, "90th_percentile": 231.8, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 231.8, "10th_percentile": 231.8, "90th_percentile": 231.8, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 231.8, "10th_percentile": 231.8, "90th_percentile": 231.8, "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": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 65.11, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.11, "10th_percentile": 65.11, "90th_percentile": 65.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 65.11, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.11, "10th_percentile": 65.11, "90th_percentile": 65.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 90.29, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 90.29, "10th_percentile": 90.29, "90th_percentile": 90.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 90.29, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 90.29, "10th_percentile": 90.29, "90th_percentile": 90.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 82.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 82.71, "10th_percentile": 82.71, "90th_percentile": 82.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 82.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 82.71, "10th_percentile": 82.71, "90th_percentile": 82.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 82.29, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 82.29, "10th_percentile": 82.29, "90th_percentile": 82.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 79.74, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 79.74, "10th_percentile": 79.74, "90th_percentile": 79.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 112.89, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 112.89, "10th_percentile": 112.89, "90th_percentile": 112.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 44.74, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 44.74, "10th_percentile": 44.74, "90th_percentile": 44.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 121.7, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 121.7, "10th_percentile": 121.7, "90th_percentile": 121.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 231.8, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 231.8, "10th_percentile": 231.8, "90th_percentile": 231.8, "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 68.36, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.36, "10th_percentile": 68.36, "90th_percentile": 68.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 115.9, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 115.9, "10th_percentile": 115.9, "90th_percentile": 115.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 162.26, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 162.26, "10th_percentile": 162.26, "90th_percentile": 162.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 169.21, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 169.21, "10th_percentile": 169.21, "90th_percentile": 169.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 122.16, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.16, "10th_percentile": 122.16, "90th_percentile": 122.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 70.35, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 70.35, "10th_percentile": 70.35, "90th_percentile": 70.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 146.03, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $146.03 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 146.03, "10th_percentile": 146.03, "90th_percentile": 146.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $146.03 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 231.8, "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 $231.80 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 231.8, "10th_percentile": 231.8, "90th_percentile": 231.8, "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 $231.80 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 45.66, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.66, "10th_percentile": 45.66, "90th_percentile": 45.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 185.44, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 185.44, "10th_percentile": 185.44, "90th_percentile": 185.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 71.63, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.63, "10th_percentile": 71.63, "90th_percentile": 71.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 173.85, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 173.85, "10th_percentile": 173.85, "90th_percentile": 173.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 123.32, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 123.32, "10th_percentile": 123.32, "90th_percentile": 123.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 148.89, "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": 148.89, "10th_percentile": 148.89, "90th_percentile": 148.89, "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": "NWR UHC CORE", "standard_charge_dollar": 109.87, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 109.87, "10th_percentile": 109.87, "90th_percentile": 109.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "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": 260.96, "maximum": 1352.14, "setting": "outpatient", "gross_charge": 1352.14, "discounted_cash": 946.5, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 394.82, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 394.82, "10th_percentile": 394.82, "90th_percentile": 394.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 465.14, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 465.14, "10th_percentile": 465.14, "90th_percentile": 465.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 260.96, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 712.58, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 417.81, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,352.14 @ 12.5% = $169.02 due to $0.00 Claim Price", "median_amount": 169.02, "10th_percentile": 169.02, "90th_percentile": 169.02, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,352.14 @ 12.5% = $169.02 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1352.14, "10th_percentile": 1352.14, "90th_percentile": 1352.14, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1352.14, "10th_percentile": 1352.14, "90th_percentile": 1352.14, "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": "NWR BCBS PPO", "standard_charge_dollar": 458.38, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 458.38, "10th_percentile": 458.38, "90th_percentile": 458.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 458.38, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 458.38, "10th_percentile": 458.38, "90th_percentile": 458.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 394.82, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 394.82, "10th_percentile": 394.82, "90th_percentile": 394.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 482.44, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 482.44, "10th_percentile": 482.44, "90th_percentile": 482.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 482.44, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 482.44, "10th_percentile": 482.44, "90th_percentile": 482.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 480.01, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 480.01, "10th_percentile": 480.01, "90th_percentile": 480.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 719.34, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 719.34, "10th_percentile": 719.34, "90th_percentile": 719.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 946.5, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 946.5, "10th_percentile": 946.5, "90th_percentile": 946.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 676.07, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 676.07, "10th_percentile": 676.07, "90th_percentile": 676.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 987.06, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 987.06, "10th_percentile": 987.06, "90th_percentile": 987.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 410.37, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 410.37, "10th_percentile": 410.37, "90th_percentile": 410.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1352.14, "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 $1,352.14 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1352.14, "10th_percentile": 1352.14, "90th_percentile": 1352.14, "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 $1,352.14 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 851.85, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $851.85 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 851.85, "10th_percentile": 851.85, "90th_percentile": 851.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $851.85 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1352.14, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1352.14, "10th_percentile": 1352.14, "90th_percentile": 1352.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1014.11, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1014.11, "10th_percentile": 1014.11, "90th_percentile": 1014.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 266.37, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 266.37, "10th_percentile": 266.37, "90th_percentile": 266.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 868.48, "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": 868.48, "10th_percentile": 868.48, "90th_percentile": 868.48, "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": "NWR BEECHSTREET", "standard_charge_dollar": 1081.71, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1081.71, "10th_percentile": 1081.71, "90th_percentile": 1081.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 640.91, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 640.91, "10th_percentile": 640.91, "90th_percentile": 640.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 646.32, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 646.32, "10th_percentile": 646.32, "90th_percentile": 646.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 646.32, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 646.32, "10th_percentile": 646.32, "90th_percentile": 646.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 646.32, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 646.32, "10th_percentile": 646.32, "90th_percentile": 646.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "6FR SAFE SHEATH II HEMOSTATIC TEAR AWAY INTRODUCER SYSTEM WITH INFUSION SIDE PORT", "code_information": [ { "code": "SUP-357878", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 124.27, "maximum": 643.88, "setting": "outpatient", "gross_charge": 643.88, "discounted_cash": 450.72, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 339.32, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.12, "10th_percentile": 47.12, "90th_percentile": 47.12, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 198.96, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 83.83, "10th_percentile": 83.83, "90th_percentile": 83.83, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 126.84, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.71, "10th_percentile": 55.71, "90th_percentile": 55.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 405.64, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $405.64 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 405.64, "10th_percentile": 405.64, "90th_percentile": 405.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $405.64 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 643.88, "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 $643.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 643.88, "10th_percentile": 643.88, "90th_percentile": 643.88, "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 $643.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 515.1, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 515.1, "10th_percentile": 515.1, "90th_percentile": 515.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 643.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 643.88, "10th_percentile": 643.88, "90th_percentile": 643.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 305.2, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 305.2, "10th_percentile": 305.2, "90th_percentile": 305.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 321.94, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 321.94, "10th_percentile": 321.94, "90th_percentile": 321.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 195.42, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 195.42, "10th_percentile": 195.42, "90th_percentile": 195.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 413.56, "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": 413.56, "10th_percentile": 413.56, "90th_percentile": 413.56, "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": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 482.91, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 482.91, "10th_percentile": 482.91, "90th_percentile": 482.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 470.03, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 470.03, "10th_percentile": 470.03, "90th_percentile": 470.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 338.04, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 338.04, "10th_percentile": 338.04, "90th_percentile": 338.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 221.49, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 221.49, "10th_percentile": 221.49, "90th_percentile": 221.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 228.58, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 228.58, "10th_percentile": 228.58, "90th_percentile": 228.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 124.27, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 124.27, "10th_percentile": 124.27, "90th_percentile": 124.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 313.57, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 313.57, "10th_percentile": 313.57, "90th_percentile": 313.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 342.54, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 342.54, "10th_percentile": 342.54, "90th_percentile": 342.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 450.72, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 450.72, "10th_percentile": 450.72, "90th_percentile": 450.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 229.74, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 229.74, "10th_percentile": 229.74, "90th_percentile": 229.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 229.74, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 229.74, "10th_percentile": 229.74, "90th_percentile": 229.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 218.28, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 218.28, "10th_percentile": 218.28, "90th_percentile": 218.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 218.28, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 218.28, "10th_percentile": 218.28, "90th_percentile": 218.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 307.77, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 307.77, "10th_percentile": 307.77, "90th_percentile": 307.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 307.77, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 307.77, "10th_percentile": 307.77, "90th_percentile": 307.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 307.77, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 307.77, "10th_percentile": 307.77, "90th_percentile": 307.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 643.88, "10th_percentile": 643.88, "90th_percentile": 643.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 643.88, "10th_percentile": 643.88, "90th_percentile": 643.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $643.88 @ 12.5% = $80.49 due to $0.00 Claim Price", "median_amount": 80.49, "10th_percentile": 80.49, "90th_percentile": 80.49, "count": "0", "methodology": "other", "additional_payer_notes": "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: $643.88 @ 12.5% = $80.49 due to $0.00 Claim Price" } ] } ] }, { "description": "6FR X 110CM TUOHY BORST SIDE ARM INTRODUCER FLEXOR SHUTTLE", "code_information": [ { "code": "SUP-365344", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 85.74, "maximum": 444.27, "setting": "outpatient", "gross_charge": 444.27, "discounted_cash": 310.99, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 234.13, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.12, "10th_percentile": 47.12, "90th_percentile": 47.12, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 137.28, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 83.83, "10th_percentile": 83.83, "90th_percentile": 83.83, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 87.52, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.71, "10th_percentile": 55.71, "90th_percentile": 55.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 279.89, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $279.89 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 279.89, "10th_percentile": 279.89, "90th_percentile": 279.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $279.89 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 444.27, "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 $444.27 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 444.27, "10th_percentile": 444.27, "90th_percentile": 444.27, "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 $444.27 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 355.42, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 355.42, "10th_percentile": 355.42, "90th_percentile": 355.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 444.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 444.27, "10th_percentile": 444.27, "90th_percentile": 444.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 210.58, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 210.58, "10th_percentile": 210.58, "90th_percentile": 210.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 222.14, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 222.14, "10th_percentile": 222.14, "90th_percentile": 222.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 134.84, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 134.84, "10th_percentile": 134.84, "90th_percentile": 134.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 285.35, "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": 285.35, "10th_percentile": 285.35, "90th_percentile": 285.35, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 333.2, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 333.2, "10th_percentile": 333.2, "90th_percentile": 333.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 324.32, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 324.32, "10th_percentile": 324.32, "90th_percentile": 324.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 233.24, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 233.24, "10th_percentile": 233.24, "90th_percentile": 233.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 152.83, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 152.83, "10th_percentile": 152.83, "90th_percentile": 152.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 157.72, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 157.72, "10th_percentile": 157.72, "90th_percentile": 157.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 85.74, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 85.74, "10th_percentile": 85.74, "90th_percentile": 85.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 216.36, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 216.36, "10th_percentile": 216.36, "90th_percentile": 216.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 236.35, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 236.35, "10th_percentile": 236.35, "90th_percentile": 236.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 310.99, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 310.99, "10th_percentile": 310.99, "90th_percentile": 310.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 158.52, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 158.52, "10th_percentile": 158.52, "90th_percentile": 158.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 158.52, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 158.52, "10th_percentile": 158.52, "90th_percentile": 158.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 150.61, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 150.61, "10th_percentile": 150.61, "90th_percentile": 150.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 150.61, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 150.61, "10th_percentile": 150.61, "90th_percentile": 150.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 212.36, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 212.36, "10th_percentile": 212.36, "90th_percentile": 212.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 212.36, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 212.36, "10th_percentile": 212.36, "90th_percentile": 212.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 212.36, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 212.36, "10th_percentile": 212.36, "90th_percentile": 212.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 444.27, "10th_percentile": 444.27, "90th_percentile": 444.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 444.27, "10th_percentile": 444.27, "90th_percentile": 444.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $444.27 @ 12.5% = $55.53 due to $0.00 Claim Price", "median_amount": 55.53, "10th_percentile": 55.53, "90th_percentile": 55.53, "count": "0", "methodology": "other", "additional_payer_notes": "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: $444.27 @ 12.5% = $55.53 due to $0.00 Claim Price" } ] } ] }, { "description": "7CM THORACIC PLATE TI.5", "code_information": [ { "code": "SUP-306231", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $0.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1188.6, "10th_percentile": 1188.6, "90th_percentile": 1188.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1001.28, "10th_percentile": 1001.28, "90th_percentile": 1001.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $0.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2627.73, "10th_percentile": 2627.73, "90th_percentile": 2627.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $0.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." } ] } ] }, { "description": "ABSORBATACK 5MM LAP HERNIA FIXATION DEVICE (ABSTACK30X)", "code_information": [ { "code": "SUP-317207", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 586.42, "maximum": 3038.45, "setting": "outpatient", "gross_charge": 3038.45, "discounted_cash": 2126.91, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3038.45, "10th_percentile": 3038.45, "90th_percentile": 3038.45, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3038.45, "10th_percentile": 3038.45, "90th_percentile": 3038.45, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3038.45, "10th_percentile": 3038.45, "90th_percentile": 3038.45, "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": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 853.5, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 853.5, "10th_percentile": 853.5, "90th_percentile": 853.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 853.5, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 853.5, "10th_percentile": 853.5, "90th_percentile": 853.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1183.48, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1183.48, "10th_percentile": 1183.48, "90th_percentile": 1183.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1183.48, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1183.48, "10th_percentile": 1183.48, "90th_percentile": 1183.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 1084.12, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1084.12, "10th_percentile": 1084.12, "90th_percentile": 1084.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1084.12, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1084.12, "10th_percentile": 1084.12, "90th_percentile": 1084.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1078.65, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1078.65, "10th_percentile": 1078.65, "90th_percentile": 1078.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 1045.23, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1045.23, "10th_percentile": 1045.23, "90th_percentile": 1045.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 1479.73, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1479.73, "10th_percentile": 1479.73, "90th_percentile": 1479.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 586.42, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 586.42, "10th_percentile": 586.42, "90th_percentile": 586.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1595.19, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1595.19, "10th_percentile": 1595.19, "90th_percentile": 1595.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 3038.45, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3038.45, "10th_percentile": 3038.45, "90th_percentile": 3038.45, "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 896.04, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 896.04, "10th_percentile": 896.04, "90th_percentile": 896.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1519.23, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1519.23, "10th_percentile": 1519.23, "90th_percentile": 1519.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2126.92, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 2126.92, "10th_percentile": 2126.92, "90th_percentile": 2126.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 2218.07, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 2218.07, "10th_percentile": 2218.07, "90th_percentile": 2218.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1601.26, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1601.26, "10th_percentile": 1601.26, "90th_percentile": 1601.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 922.17, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 922.17, "10th_percentile": 922.17, "90th_percentile": 922.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1914.22, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,914.22 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1914.22, "10th_percentile": 1914.22, "90th_percentile": 1914.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,914.22 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3038.45, "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 $3,038.45 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3038.45, "10th_percentile": 3038.45, "90th_percentile": 3038.45, "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 $3,038.45 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 598.57, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 598.57, "10th_percentile": 598.57, "90th_percentile": 598.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 2430.76, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2430.76, "10th_percentile": 2430.76, "90th_percentile": 2430.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 938.88, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 938.88, "10th_percentile": 938.88, "90th_percentile": 938.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2278.84, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 2278.84, "10th_percentile": 2278.84, "90th_percentile": 2278.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1616.46, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1616.46, "10th_percentile": 1616.46, "90th_percentile": 1616.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 1951.6, "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": 1951.6, "10th_percentile": 1951.6, "90th_percentile": 1951.6, "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": "NWR UHC CORE", "standard_charge_dollar": 1440.23, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1440.23, "10th_percentile": 1440.23, "90th_percentile": 1440.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "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": 450.68, "maximum": 2335.12, "setting": "outpatient", "gross_charge": 2335.12, "discounted_cash": 1634.58, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 721.55, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 450.68, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $2,335.12 @ 12.5% = $291.89 due to $0.00 Claim Price", "median_amount": 291.89, "10th_percentile": 291.89, "90th_percentile": 291.89, "count": "0", "methodology": "other", "additional_payer_notes": "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: $2,335.12 @ 12.5% = $291.89 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2335.12, "10th_percentile": 2335.12, "90th_percentile": 2335.12, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2335.12, "10th_percentile": 2335.12, "90th_percentile": 2335.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 791.61, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 791.61, "10th_percentile": 791.61, "90th_percentile": 791.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 791.61, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 791.61, "10th_percentile": 791.61, "90th_percentile": 791.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 681.86, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 681.86, "10th_percentile": 681.86, "90th_percentile": 681.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 681.86, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 681.86, "10th_percentile": 681.86, "90th_percentile": 681.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 833.17, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 833.17, "10th_percentile": 833.17, "90th_percentile": 833.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 833.17, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 833.17, "10th_percentile": 833.17, "90th_percentile": 833.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 803.28, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 803.28, "10th_percentile": 803.28, "90th_percentile": 803.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1167.56, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1167.56, "10th_percentile": 1167.56, "90th_percentile": 1167.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1868.1, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1868.1, "10th_percentile": 1868.1, "90th_percentile": 1868.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 828.97, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 828.97, "10th_percentile": 828.97, "90th_percentile": 828.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 460.02, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 460.02, "10th_percentile": 460.02, "90th_percentile": 460.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1751.34, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1751.34, "10th_percentile": 1751.34, "90th_percentile": 1751.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1242.28, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1242.28, "10th_percentile": 1242.28, "90th_percentile": 1242.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2335.12, "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 $2,335.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2335.12, "10th_percentile": 2335.12, "90th_percentile": 2335.12, "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 $2,335.12 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1634.58, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1634.58, "10th_percentile": 1634.58, "90th_percentile": 1634.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1704.64, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1704.64, "10th_percentile": 1704.64, "90th_percentile": 1704.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 708.71, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 708.71, "10th_percentile": 708.71, "90th_percentile": 708.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1116.19, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1116.19, "10th_percentile": 1116.19, "90th_percentile": 1116.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1116.19, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1116.19, "10th_percentile": 1116.19, "90th_percentile": 1116.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1116.19, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1116.19, "10th_percentile": 1116.19, "90th_percentile": 1116.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1230.61, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1471.13, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,471.13 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1471.13, "10th_percentile": 1471.13, "90th_percentile": 1471.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,471.13 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 1106.85, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1106.85, "10th_percentile": 1106.85, "90th_percentile": 1106.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 1499.85, "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": 1499.85, "10th_percentile": 1499.85, "90th_percentile": 1499.85, "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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 2335.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2335.12, "10th_percentile": 2335.12, "90th_percentile": 2335.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ACETAMINOPHEN 325 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-101", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "57896-0102-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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": "NWR 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": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR BLUE CROSS MEDICARE ADVT", "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": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $2.00 @ 12.5% = $0.25 due to $0.00 Claim Price", "median_amount": 0.25, "10th_percentile": 0.25, "90th_percentile": 0.25, "count": "0", "methodology": "other", "additional_payer_notes": "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: $2.00 @ 12.5% = $0.25 due to $0.00 Claim Price" } ] } ] }, { "description": "ACETAMINOPHEN 500 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-102", "type": "CDM" }, { "code": "CHRG1625", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "57896-0222-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR 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": "NWR 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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ACETAMINOPHEN 500 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-102", "type": "CDM" }, { "code": "CHRG1625", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "71399-8022-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR 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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ACETAMINOPHEN 500 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-102", "type": "CDM" }, { "code": "CHRG1625", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "71399-8027-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR 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": "NWR 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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ACETAMINOPHEN-CAFFEINE 500-65 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-84336", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "00067-2045-91", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $2.00 @ 12.5% = $0.25 due to $0.00 Claim Price", "median_amount": 0.25, "10th_percentile": 0.25, "90th_percentile": 0.25, "count": "0", "methodology": "other", "additional_payer_notes": "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: $2.00 @ 12.5% = $0.25 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR BLUE CROSS MEDICARE ADVT", "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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." } ] } ] }, { "description": "ACETAZOLAMIDE 250 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-113", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "70756-0721-11", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR 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": "NWR BLUE CROSS MEDICARE ADVT", "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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ACETIC ACID (BULK) 3 % MISC LIQD", "drug_information": { "unit": 20.0, "type": "ML" }, "code_information": [ { "code": "RX-172862", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "51552-0051-06", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.01, "maximum": 5.25, "setting": "outpatient", "gross_charge": 5.25, "discounted_cash": 3.67, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.25, "10th_percentile": 5.25, "90th_percentile": 5.25, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.25, "10th_percentile": 5.25, "90th_percentile": 5.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.25, "10th_percentile": 5.25, "90th_percentile": 5.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.87, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.87, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 2.04, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 2.04, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.47, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.47, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 1.01, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1.01, "10th_percentile": 1.01, "90th_percentile": 1.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1.86, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1.86, "10th_percentile": 1.86, "90th_percentile": 1.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 2.76, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 1.81, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1.81, "10th_percentile": 1.81, "90th_percentile": 1.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 2.56, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.56, "10th_percentile": 2.56, "90th_percentile": 2.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 3.83, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 3.83, "10th_percentile": 3.83, "90th_percentile": 3.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 4.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 4.2, "10th_percentile": 4.2, "90th_percentile": 4.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 2.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 2.63, "10th_percentile": 2.63, "90th_percentile": 2.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 2.79, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 2.79, "10th_percentile": 2.79, "90th_percentile": 2.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.55, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.55, "10th_percentile": 1.55, "90th_percentile": 1.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 1.03, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC CORE", "standard_charge_dollar": 2.49, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 2.49, "10th_percentile": 2.49, "90th_percentile": 2.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 3.37, "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": 3.37, "10th_percentile": 3.37, "90th_percentile": 3.37, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 3.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 3.94, "10th_percentile": 3.94, "90th_percentile": 3.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 1.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.62, "10th_percentile": 1.62, "90th_percentile": 1.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 1.59, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 1.59, "10th_percentile": 1.59, "90th_percentile": 1.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 3.68, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 3.68, "10th_percentile": 3.68, "90th_percentile": 3.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% 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 OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 2.77, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.77, "10th_percentile": 2.77, "90th_percentile": 2.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 5.25, "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 $5.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "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. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $5.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 3.31, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $3.31 so that total pmt for all claim lines does not exceed 63% 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; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $3.31 so that total pmt for all claim lines does not exceed 63% 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": "63323-0963-44", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.38, "maximum": 17.5, "setting": "outpatient", "gross_charge": 17.5, "discounted_cash": 12.25, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 17.5, "10th_percentile": 17.5, "90th_percentile": 17.5, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 17.5, "10th_percentile": 17.5, "90th_percentile": 17.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 17.5, "10th_percentile": 17.5, "90th_percentile": 17.5, "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": "NWR BCBS HMO", "standard_charge_dollar": 6.24, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.24, "10th_percentile": 6.24, "90th_percentile": 6.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 6.24, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.24, "10th_percentile": 6.24, "90th_percentile": 6.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 6.21, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 6.21, "10th_percentile": 6.21, "90th_percentile": 6.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 6.02, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 6.02, "10th_percentile": 6.02, "90th_percentile": 6.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 13.13, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 13.13, "10th_percentile": 13.13, "90th_percentile": 13.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 5.31, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 5.31, "10th_percentile": 5.31, "90th_percentile": 5.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 8.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 8.75, "10th_percentile": 8.75, "90th_percentile": 8.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 9.19, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 12.78, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 12.78, "10th_percentile": 12.78, "90th_percentile": 12.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 14.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 14.0, "10th_percentile": 14.0, "90th_percentile": 14.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 17.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 17.5, "10th_percentile": 17.5, "90th_percentile": 17.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 3.38, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 12.25, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 9.31, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 9.31, "10th_percentile": 9.31, "90th_percentile": 9.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 17.5, "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 $17.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 17.5, "10th_percentile": 17.5, "90th_percentile": 17.5, "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 $17.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 11.03, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $11.03 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 11.03, "10th_percentile": 11.03, "90th_percentile": 11.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $11.03 so that total pmt for all claim lines does not exceed 63% 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": 2.8, "maximum": 14.5, "setting": "outpatient", "gross_charge": 14.5, "discounted_cash": 10.15, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14.5, "10th_percentile": 14.5, "90th_percentile": 14.5, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14.5, "10th_percentile": 14.5, "90th_percentile": 14.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14.5, "10th_percentile": 14.5, "90th_percentile": 14.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 9.14, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $9.14 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 9.14, "10th_percentile": 9.14, "90th_percentile": 9.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $9.14 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 14.5, "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 $14.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 14.5, "10th_percentile": 14.5, "90th_percentile": 14.5, "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 $14.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 2.8, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% 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 Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 4.99, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% 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; 34.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.5, "10th_percentile": 14.5, "90th_percentile": 14.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 7.71, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 7.71, "10th_percentile": 7.71, "90th_percentile": 7.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 11.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 5.15, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 5.15, "10th_percentile": 5.15, "90th_percentile": 5.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 10.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 10.88, "10th_percentile": 10.88, "90th_percentile": 10.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 7.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 7.25, "10th_percentile": 7.25, "90th_percentile": 7.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 10.59, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 10.59, "10th_percentile": 10.59, "90th_percentile": 10.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 4.4, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 4.4, "10th_percentile": 4.4, "90th_percentile": 4.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 10.15, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 10.15, "10th_percentile": 10.15, "90th_percentile": 10.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 7.61, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.61, "10th_percentile": 7.61, "90th_percentile": 7.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 5.17, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.17, "10th_percentile": 5.17, "90th_percentile": 5.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 5.17, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.17, "10th_percentile": 5.17, "90th_percentile": 5.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION", "code_information": [ { "code": "880", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 6832.62, "maximum": 11739.41, "setting": "inpatient", "gross_charge": 40242.24, "discounted_cash": 28169.57, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 11739.41, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.9602, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 77204.5, "10th_percentile": 77204.5, "90th_percentile": 77204.5, "count": "17", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 7529.89, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.9602, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 61887.47, "10th_percentile": 61887.47, "90th_percentile": 61887.47, "count": "17", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 7680.64, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.9602, Rate: 7,999.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 98312.32, "10th_percentile": 98312.32, "90th_percentile": 98312.32, "count": "17", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 7832.35, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.9602, Rate: 8,157.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 7832.35, "10th_percentile": 7832.35, "90th_percentile": 7832.35, "count": "17", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 7529.89, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.9602, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 7529.89, "10th_percentile": 7529.89, "90th_percentile": 7529.89, "count": "17", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 11739.41, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.9602, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 77204.5, "10th_percentile": 77204.5, "90th_percentile": 77204.5, "count": "17", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 7529.89, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.9602, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 61887.47, "10th_percentile": 61887.47, "90th_percentile": 61887.47, "count": "17", "methodology": "case rate" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_percentage": 34.5, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; Inpatient; 34.5% Billed", "median_amount": 13961.03, "10th_percentile": 13961.03, "90th_percentile": 13961.03, "count": "17", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_percentage": 36.1, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; Inpatient; 36.1% Billed", "median_amount": 14608.5, "10th_percentile": 14608.5, "90th_percentile": 14608.5, "count": "17", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_percentage": 19.3, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 7810.09, "10th_percentile": 7810.09, "90th_percentile": 7810.09, "count": "17", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; Stop Loss; 70% Billed", "median_amount": 28326.73, "10th_percentile": 28326.73, "90th_percentile": 28326.73, "count": "17", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_percentage": 73.0, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; All Inpatient Services; 73% Billed", "median_amount": 29540.73, "10th_percentile": 29540.73, "90th_percentile": 29540.73, "count": "17", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; Inpatient Services; 50% Billed", "median_amount": 20233.38, "10th_percentile": 20233.38, "90th_percentile": 20233.38, "count": "17", "methodology": "percent of total billed charges" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; Inpatient; 30.35% Billed", "median_amount": 12281.66, "10th_percentile": 12281.66, "90th_percentile": 12281.66, "count": "17", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; All IP Services; 100% Billed", "median_amount": 40466.75, "10th_percentile": 40466.75, "90th_percentile": 40466.75, "count": "17", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_percentage": 50.8, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; Inpatient; 50.8% Billed", "median_amount": 20557.11, "10th_percentile": 20557.11, "90th_percentile": 20557.11, "count": "17", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 30350.06, "10th_percentile": 30350.06, "90th_percentile": 30350.06, "count": "17", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 71.3, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; IP Services. ADP RATE (for patient estimates only); 71.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28852.79, "10th_percentile": 28852.79, "90th_percentile": 28852.79, "count": "17", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; Inpatient; 80% Billed", "median_amount": 32373.4, "10th_percentile": 32373.4, "90th_percentile": 32373.4, "count": "17", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_dollar": 6832.62, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.96, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $7,920.41; Total: $7,920.41 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7920.41, "10th_percentile": 7920.41, "90th_percentile": 7920.41, "count": "17", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.96, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $7,920.41; Total: $7,920.41 Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 6832.62, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.96, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $7,920.41; Total: $7,920.41 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7920.41, "10th_percentile": 7920.41, "90th_percentile": 7920.41, "count": "17", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.96, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $7,920.41; Total: $7,920.41 Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 10444.1, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.9602, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 63% of charges. Total pmt for all lines paid so far is less than 63% of claim billed amount.", "median_amount": 10444.1, "10th_percentile": 10444.1, "90th_percentile": 10444.1, "count": "17", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.9602, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 63% of charges. Total pmt for all lines paid so far is less than 63% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_dollar": 6832.62, "standard_charge_algorithm": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.96, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $7,920.41; Total: $7,920.41", "median_amount": 7920.41, "10th_percentile": 7920.41, "90th_percentile": 7920.41, "count": "17", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.749937033; Using historical claim(s); Scope: All Financial Classes; Cases: 17; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.96, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $7,920.41; Total: $7,920.41" } ] } ] }, { "description": "ACUTE MAJOR EYE INFECTIONS WITH CC/MCC", "code_information": [ { "code": "121", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 8277.85, "maximum": 14222.51, "setting": "inpatient", "gross_charge": 46458.74, "discounted_cash": 32521.12, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_percentage": 19.3, "standard_charge_algorithm": "Additional drugs, labs, radiology services, therapy services, and other services can be included in reimbursement.", "median_amount": 9039.88, "10th_percentile": 9039.88, "90th_percentile": 9039.88, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_percentage": 36.1, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient; 36.1% Billed", "median_amount": 16908.79, "10th_percentile": 16908.79, "90th_percentile": 16908.79, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_percentage": 34.5, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient; 34.5% Billed", "median_amount": 16159.37, "10th_percentile": 16159.37, "90th_percentile": 16159.37, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Stop Loss; 70% Billed", "median_amount": 32787.13, "10th_percentile": 32787.13, "90th_percentile": 32787.13, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_percentage": 73.0, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All Inpatient Services; 73% Billed", "median_amount": 34192.29, "10th_percentile": 34192.29, "90th_percentile": 34192.29, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 71.3, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; IP Services. ADP RATE (for patient estimates only); 71.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33396.03, "10th_percentile": 33396.03, "90th_percentile": 33396.03, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient; 80% Billed", "median_amount": 37471.0, "10th_percentile": 37471.0, "90th_percentile": 37471.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_percentage": 50.8, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient; 50.8% Billed", "median_amount": 23794.09, "10th_percentile": 23794.09, "90th_percentile": 23794.09, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient; 30.35% Billed", "median_amount": 14215.56, "10th_percentile": 14215.56, "90th_percentile": 14215.56, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; 100% Billed", "median_amount": 46838.75, "10th_percentile": 46838.75, "90th_percentile": 46838.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient Services; 50% Billed", "median_amount": 23419.38, "10th_percentile": 23419.38, "90th_percentile": 23419.38, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "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": 35129.06, "10th_percentile": 35129.06, "90th_percentile": 35129.06, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 14222.51, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 14222.51, "10th_percentile": 14222.51, "90th_percentile": 14222.51, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 9122.6, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 9122.6, "10th_percentile": 9122.6, "90th_percentile": 9122.6, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 14222.51, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 14222.51, "10th_percentile": 14222.51, "90th_percentile": 14222.51, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 9122.6, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 9122.6, "10th_percentile": 9122.6, "90th_percentile": 9122.6, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 9489.04, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 8,157.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 9489.04, "10th_percentile": 9489.04, "90th_percentile": 9489.04, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 9122.6, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 9122.6, "10th_percentile": 9122.6, "90th_percentile": 9122.6, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 9305.24, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 7,999.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 9305.24, "10th_percentile": 9305.24, "90th_percentile": 9305.24, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 8277.85, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; 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 CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $9,511.55; Total: $9,511.55 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9511.55, "10th_percentile": 9511.55, "90th_percentile": 9511.55, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.769171326; 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 CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $9,511.55; Total: $9,511.55 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_dollar": 8277.85, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; 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 CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $9,511.55; Total: $9,511.55 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9511.55, "10th_percentile": 9511.55, "90th_percentile": 9511.55, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.769171326; 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 CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $9,511.55; Total: $9,511.55 Paid at contractual rate, which is the lesser 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": "NWR MEDICARE", "standard_charge_dollar": 8277.85, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; 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: Base payment: $10,100.05; Total: $10,100.05", "median_amount": 10100.05, "10th_percentile": 10100.05, "90th_percentile": 10100.05, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.769171326; 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: Base payment: $10,100.05; Total: $10,100.05" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 12653.21, "standard_charge_algorithm": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 63% of charges. Total pmt for all lines paid so far is less than 63% of claim billed amount.", "median_amount": 12653.21, "10th_percentile": 12653.21, "90th_percentile": 12653.21, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.769171326; Using historical claim(s); Scope: All Financial Classes; Cases: 1; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 63% of charges. Total pmt for all lines paid so far is less than 63% of claim billed amount." } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC", "code_information": [ { "code": "283", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 14095.04, "maximum": 24217.26, "setting": "inpatient", "gross_charge": 60592.0, "discounted_cash": 42414.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 24217.26, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 24217.26, "10th_percentile": 24217.26, "90th_percentile": 24217.26, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 15844.42, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 7,999.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 15844.42, "10th_percentile": 15844.42, "90th_percentile": 15844.42, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 15533.43, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 15533.43, "10th_percentile": 15533.43, "90th_percentile": 15533.43, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 16157.39, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 8,157.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 16157.39, "10th_percentile": 16157.39, "90th_percentile": 16157.39, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 15533.43, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 15533.43, "10th_percentile": 15533.43, "90th_percentile": 15533.43, "count": "11", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 15533.43, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 15533.43, "10th_percentile": 15533.43, "90th_percentile": 15533.43, "count": "11", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 24217.26, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 24217.26, "10th_percentile": 24217.26, "90th_percentile": 24217.26, "count": "11", "methodology": "case rate" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 45511.69, "10th_percentile": 45511.69, "90th_percentile": 45511.69, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_percentage": 50.8, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; 50.8% Billed", "median_amount": 30826.58, "10th_percentile": 30826.58, "90th_percentile": 30826.58, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; 30.35% Billed", "median_amount": 18417.06, "10th_percentile": 18417.06, "90th_percentile": 18417.06, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient Services; 50% Billed", "median_amount": 30341.13, "10th_percentile": 30341.13, "90th_percentile": 30341.13, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; 100% Billed", "median_amount": 60682.25, "10th_percentile": 60682.25, "90th_percentile": 60682.25, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; 80% Billed", "median_amount": 48545.8, "10th_percentile": 48545.8, "90th_percentile": 48545.8, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 71.3, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; IP Services. ADP RATE (for patient estimates only); 71.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43266.44, "10th_percentile": 43266.44, "90th_percentile": 43266.44, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Stop Loss; 70% Billed", "median_amount": 42477.58, "10th_percentile": 42477.58, "90th_percentile": 42477.58, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_percentage": 73.0, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All Inpatient Services; 73% Billed", "median_amount": 44298.04, "10th_percentile": 44298.04, "90th_percentile": 44298.04, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_percentage": 36.1, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; 36.1% Billed", "median_amount": 21906.29, "10th_percentile": 21906.29, "90th_percentile": 21906.29, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_percentage": 34.5, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; 34.5% Billed", "median_amount": 20935.38, "10th_percentile": 20935.38, "90th_percentile": 20935.38, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_percentage": 19.3, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 11711.68, "10th_percentile": 11711.68, "90th_percentile": 11711.68, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 21545.16, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 63% of charges. Total pmt for all lines paid so far is less than 63% of claim billed amount.", "median_amount": 21545.16, "10th_percentile": 21545.16, "90th_percentile": 21545.16, "count": "11", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 63% of charges. Total pmt for all lines paid so far is less than 63% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_dollar": 14095.04, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.98, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $15,916.06; Total: $15,916.06", "median_amount": 15916.06, "10th_percentile": 15916.06, "90th_percentile": 15916.06, "count": "11", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.837917379; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.98, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $15,916.06; Total: $15,916.06" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_dollar": 14095.04, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; 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 CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $15,916.06; Total: $15,916.06 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15916.06, "10th_percentile": 15916.06, "90th_percentile": 15916.06, "count": "11", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.837917379; 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 CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $15,916.06; Total: $15,916.06 Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 14095.04, "standard_charge_algorithm": "Re-evaluated: HLB.837917379; 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 CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $15,916.06; Total: $15,916.06 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15916.06, "10th_percentile": 15916.06, "90th_percentile": 15916.06, "count": "11", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.837917379; 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 CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $15,916.06; Total: $15,916.06 Paid at contractual rate, which is 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": "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": 3.57, "maximum": 18.5, "setting": "outpatient", "gross_charge": 18.5, "discounted_cash": 12.95, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 18.5, "10th_percentile": 18.5, "90th_percentile": 18.5, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 18.5, "10th_percentile": 18.5, "90th_percentile": 18.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 18.5, "10th_percentile": 18.5, "90th_percentile": 18.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 11.66, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $11.66 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 11.66, "10th_percentile": 11.66, "90th_percentile": 11.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $11.66 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 18.5, "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 $18.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 18.5, "10th_percentile": 18.5, "90th_percentile": 18.5, "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 $18.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 3.57, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 3.57, "10th_percentile": 3.57, "90th_percentile": 3.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 6.36, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 6.36, "10th_percentile": 6.36, "90th_percentile": 6.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 18.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 18.5, "10th_percentile": 18.5, "90th_percentile": 18.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 9.84, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 9.84, "10th_percentile": 9.84, "90th_percentile": 9.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 14.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 14.8, "10th_percentile": 14.8, "90th_percentile": 14.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 6.57, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 6.57, "10th_percentile": 6.57, "90th_percentile": 6.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 13.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 13.88, "10th_percentile": 13.88, "90th_percentile": 13.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 9.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 9.25, "10th_percentile": 9.25, "90th_percentile": 9.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 13.51, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 13.51, "10th_percentile": 13.51, "90th_percentile": 13.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 5.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 5.61, "10th_percentile": 5.61, "90th_percentile": 5.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 12.95, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 12.95, "10th_percentile": 12.95, "90th_percentile": 12.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 9.71, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.71, "10th_percentile": 9.71, "90th_percentile": 9.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 6.6, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.6, "10th_percentile": 6.6, "90th_percentile": 6.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 6.6, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.6, "10th_percentile": 6.6, "90th_percentile": 6.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ADAPTA S PACEMAKER", "code_information": [ { "code": "SUP-117685", "type": "CDM" }, { "code": "C1785", "type": "HCPCS" }, { "code": "0275", "type": "RC" } ], "standard_charges": [ { "minimum": 3117.47, "maximum": 16152.68, "setting": "outpatient", "gross_charge": 16152.68, "discounted_cash": 11306.88, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 7720.98, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7720.98, "10th_percentile": 7720.98, "90th_percentile": 7720.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 7720.98, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7720.98, "10th_percentile": 7720.98, "90th_percentile": 7720.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 7720.98, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7720.98, "10th_percentile": 7720.98, "90th_percentile": 7720.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 5763.28, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5763.28, "10th_percentile": 5763.28, "90th_percentile": 5763.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 5763.28, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5763.28, "10th_percentile": 5763.28, "90th_percentile": 5763.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 16152.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 16152.68, "10th_percentile": 16152.68, "90th_percentile": 16152.68, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 16152.68, "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 $16,152.68 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 16152.68, "10th_percentile": 16152.68, "90th_percentile": 16152.68, "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 $16,152.68 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": "NWR BCBS PPO", "standard_charge_dollar": 5475.76, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5475.76, "10th_percentile": 5475.76, "90th_percentile": 5475.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 4716.58, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 275; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4716.58, "10th_percentile": 4716.58, "90th_percentile": 4716.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 275; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 5556.52, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 5556.52, "10th_percentile": 5556.52, "90th_percentile": 5556.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 4716.58, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 275; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4716.58, "10th_percentile": 4716.58, "90th_percentile": 4716.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 275; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 5734.2, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 5734.2, "10th_percentile": 5734.2, "90th_percentile": 5734.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 3117.47, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 3117.47, "10th_percentile": 3117.47, "90th_percentile": 3117.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 5475.76, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5475.76, "10th_percentile": 5475.76, "90th_percentile": 5475.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 12922.14, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 12922.14, "10th_percentile": 12922.14, "90th_percentile": 12922.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 8593.23, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 8593.23, "10th_percentile": 8593.23, "90th_percentile": 8593.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 3182.08, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3182.08, "10th_percentile": 3182.08, "90th_percentile": 3182.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 12114.51, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 12114.51, "10th_percentile": 12114.51, "90th_percentile": 12114.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 4991.18, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4991.18, "10th_percentile": 4991.18, "90th_percentile": 4991.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 11306.88, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 11306.88, "10th_percentile": 11306.88, "90th_percentile": 11306.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 11791.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 11791.46, "10th_percentile": 11791.46, "90th_percentile": 11791.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 8076.34, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 8076.34, "10th_percentile": 8076.34, "90th_percentile": 8076.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 4902.34, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 4902.34, "10th_percentile": 4902.34, "90th_percentile": 4902.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 10176.19, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $10,176.19 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 10176.19, "10th_percentile": 10176.19, "90th_percentile": 10176.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $10,176.19 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 10374.87, "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": 10374.87, "10th_percentile": 10374.87, "90th_percentile": 10374.87, "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": "NWR UHC CORE", "standard_charge_dollar": 7656.37, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 7656.37, "10th_percentile": 7656.37, "90th_percentile": 7656.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 8512.46, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8512.46, "10th_percentile": 8512.46, "90th_percentile": 8512.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 16152.68, "10th_percentile": 16152.68, "90th_percentile": 16152.68, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 16152.68, "10th_percentile": 16152.68, "90th_percentile": 16152.68, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $16,152.68 @ 12.5% = $2,019.09 due to $0.00 Claim Price", "median_amount": 2019.09, "10th_percentile": 2019.09, "90th_percentile": 2019.09, "count": "0", "methodology": "other", "additional_payer_notes": "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: $16,152.68 @ 12.5% = $2,019.09 due to $0.00 Claim Price" } ] } ] }, { "description": "ADAPTER EXTERNAL FIX SHORT WIRE BOLT", "code_information": [ { "code": "SUP-344141", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 172.38, "maximum": 893.18, "setting": "outpatient", "gross_charge": 893.18, "discounted_cash": 625.23, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 893.18, "10th_percentile": 893.18, "90th_percentile": 893.18, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 893.18, "10th_percentile": 893.18, "90th_percentile": 893.18, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 893.18, "10th_percentile": 893.18, "90th_percentile": 893.18, "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": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 250.89, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 250.89, "10th_percentile": 250.89, "90th_percentile": 250.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 250.89, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 250.89, "10th_percentile": 250.89, "90th_percentile": 250.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 347.89, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 347.89, "10th_percentile": 347.89, "90th_percentile": 347.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 347.89, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 347.89, "10th_percentile": 347.89, "90th_percentile": 347.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 318.69, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 318.69, "10th_percentile": 318.69, "90th_percentile": 318.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 318.69, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 318.69, "10th_percentile": 318.69, "90th_percentile": 318.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 317.08, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 317.08, "10th_percentile": 317.08, "90th_percentile": 317.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 307.25, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 307.25, "10th_percentile": 307.25, "90th_percentile": 307.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 434.98, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 434.98, "10th_percentile": 434.98, "90th_percentile": 434.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 172.38, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 172.38, "10th_percentile": 172.38, "90th_percentile": 172.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 468.92, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 468.92, "10th_percentile": 468.92, "90th_percentile": 468.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 893.18, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 893.18, "10th_percentile": 893.18, "90th_percentile": 893.18, "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 263.4, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 263.4, "10th_percentile": 263.4, "90th_percentile": 263.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 446.59, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 446.59, "10th_percentile": 446.59, "90th_percentile": 446.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 625.23, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 625.23, "10th_percentile": 625.23, "90th_percentile": 625.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 652.02, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 652.02, "10th_percentile": 652.02, "90th_percentile": 652.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 470.71, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 470.71, "10th_percentile": 470.71, "90th_percentile": 470.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 271.08, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 271.08, "10th_percentile": 271.08, "90th_percentile": 271.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 562.7, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $562.70 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 562.7, "10th_percentile": 562.7, "90th_percentile": 562.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $562.70 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 893.18, "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 $893.18 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 893.18, "10th_percentile": 893.18, "90th_percentile": 893.18, "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 $893.18 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 175.96, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 175.96, "10th_percentile": 175.96, "90th_percentile": 175.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 714.54, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 714.54, "10th_percentile": 714.54, "90th_percentile": 714.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 275.99, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 275.99, "10th_percentile": 275.99, "90th_percentile": 275.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 669.89, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 669.89, "10th_percentile": 669.89, "90th_percentile": 669.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 475.17, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 475.17, "10th_percentile": 475.17, "90th_percentile": 475.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 573.69, "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": 573.69, "10th_percentile": 573.69, "90th_percentile": 573.69, "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": "NWR UHC CORE", "standard_charge_dollar": 423.37, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 423.37, "10th_percentile": 423.37, "90th_percentile": 423.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "description": "ADAPTER IV FOUR-SPIKE C7108 5", "code_information": [ { "code": "SUP-302424", "type": "CDM" }, { "code": "27000001", "type": "LOCAL" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "minimum": 57.99, "maximum": 300.48, "setting": "outpatient", "gross_charge": 300.48, "discounted_cash": 210.34, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 107.21, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 107.21, "10th_percentile": 107.21, "90th_percentile": 107.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 107.21, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 107.21, "10th_percentile": 107.21, "90th_percentile": 107.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 117.04, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 117.04, "10th_percentile": 117.04, "90th_percentile": 117.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 117.04, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 117.04, "10th_percentile": 117.04, "90th_percentile": 117.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 84.4, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 84.4, "10th_percentile": 84.4, "90th_percentile": 84.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 84.4, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 84.4, "10th_percentile": 84.4, "90th_percentile": 84.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 300.48, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 300.48, "10th_percentile": 300.48, "90th_percentile": 300.48, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 300.48, "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 $300.48 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 300.48, "10th_percentile": 300.48, "90th_percentile": 300.48, "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 $300.48 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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 88.61, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 88.61, "10th_percentile": 88.61, "90th_percentile": 88.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 146.33, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 146.33, "10th_percentile": 146.33, "90th_percentile": 146.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 103.37, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 103.37, "10th_percentile": 103.37, "90th_percentile": 103.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 157.75, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 157.75, "10th_percentile": 157.75, "90th_percentile": 157.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 106.67, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 106.67, "10th_percentile": 106.67, "90th_percentile": 106.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 57.99, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 57.99, "10th_percentile": 57.99, "90th_percentile": 57.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 240.38, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 240.38, "10th_percentile": 240.38, "90th_percentile": 240.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 159.86, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 159.86, "10th_percentile": 159.86, "90th_percentile": 159.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 59.19, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 59.19, "10th_percentile": 59.19, "90th_percentile": 59.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 225.36, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 225.36, "10th_percentile": 225.36, "90th_percentile": 225.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 92.85, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 92.85, "10th_percentile": 92.85, "90th_percentile": 92.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 210.34, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 210.34, "10th_percentile": 210.34, "90th_percentile": 210.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 219.35, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 219.35, "10th_percentile": 219.35, "90th_percentile": 219.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 150.24, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 150.24, "10th_percentile": 150.24, "90th_percentile": 150.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 91.2, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 91.2, "10th_percentile": 91.2, "90th_percentile": 91.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 189.3, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $189.30 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 189.3, "10th_percentile": 189.3, "90th_percentile": 189.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $189.30 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 193.0, "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": 193.0, "10th_percentile": 193.0, "90th_percentile": 193.0, "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": "NWR UHC CORE", "standard_charge_dollar": 142.43, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 142.43, "10th_percentile": 142.43, "90th_percentile": 142.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 158.35, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 158.35, "10th_percentile": 158.35, "90th_percentile": 158.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 300.48, "10th_percentile": 300.48, "90th_percentile": 300.48, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 300.48, "10th_percentile": 300.48, "90th_percentile": 300.48, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 300.48, "10th_percentile": 300.48, "90th_percentile": 300.48, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "ADAPTER PIN APEX SHRT 3-6MM", "code_information": [ { "code": "SUP-350041", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 263.65, "maximum": 1366.05, "setting": "outpatient", "gross_charge": 1366.05, "discounted_cash": 956.23, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 647.51, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 647.51, "10th_percentile": 647.51, "90th_percentile": 647.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 877.41, "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": 877.41, "10th_percentile": 877.41, "90th_percentile": 877.41, "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": "NWR UHC HMO/PPO", "standard_charge_dollar": 719.91, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 719.91, "10th_percentile": 719.91, "90th_percentile": 719.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1366.05, "10th_percentile": 1366.05, "90th_percentile": 1366.05, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1366.05, "10th_percentile": 1366.05, "90th_percentile": 1366.05, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1366.05, "10th_percentile": 1366.05, "90th_percentile": 1366.05, "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": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 383.72, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 383.72, "10th_percentile": 383.72, "90th_percentile": 383.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 383.72, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 383.72, "10th_percentile": 383.72, "90th_percentile": 383.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 532.08, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 532.08, "10th_percentile": 532.08, "90th_percentile": 532.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 532.08, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 532.08, "10th_percentile": 532.08, "90th_percentile": 532.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 487.41, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 487.41, "10th_percentile": 487.41, "90th_percentile": 487.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 487.41, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 487.41, "10th_percentile": 487.41, "90th_percentile": 487.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 484.95, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 484.95, "10th_percentile": 484.95, "90th_percentile": 484.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 469.92, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 469.92, "10th_percentile": 469.92, "90th_percentile": 469.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 665.27, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 665.27, "10th_percentile": 665.27, "90th_percentile": 665.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 263.65, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 263.65, "10th_percentile": 263.65, "90th_percentile": 263.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 717.18, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 717.18, "10th_percentile": 717.18, "90th_percentile": 717.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1366.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1366.05, "10th_percentile": 1366.05, "90th_percentile": 1366.05, "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 402.85, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 402.85, "10th_percentile": 402.85, "90th_percentile": 402.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 683.03, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 683.03, "10th_percentile": 683.03, "90th_percentile": 683.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 956.24, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 956.24, "10th_percentile": 956.24, "90th_percentile": 956.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 997.22, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 997.22, "10th_percentile": 997.22, "90th_percentile": 997.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 414.6, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 414.6, "10th_percentile": 414.6, "90th_percentile": 414.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 860.61, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $860.61 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 860.61, "10th_percentile": 860.61, "90th_percentile": 860.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $860.61 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1366.05, "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 $1,366.05 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1366.05, "10th_percentile": 1366.05, "90th_percentile": 1366.05, "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 $1,366.05 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 269.11, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 269.11, "10th_percentile": 269.11, "90th_percentile": 269.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 1092.84, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1092.84, "10th_percentile": 1092.84, "90th_percentile": 1092.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 422.11, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 422.11, "10th_percentile": 422.11, "90th_percentile": 422.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1024.54, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1024.54, "10th_percentile": 1024.54, "90th_percentile": 1024.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 726.74, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 726.74, "10th_percentile": 726.74, "90th_percentile": 726.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" } ] } ] }, { "description": "ADAPTER Y ANGIO GATEWAY PLUS M001153223", "code_information": [ { "code": "SUP-351017", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 15.99, "maximum": 82.85, "setting": "outpatient", "gross_charge": 82.85, "discounted_cash": 57.99, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 82.85, "10th_percentile": 82.85, "90th_percentile": 82.85, "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": "NWR BCBS PPO", "standard_charge_dollar": 32.27, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.27, "10th_percentile": 32.27, "90th_percentile": 32.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 29.56, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.56, "10th_percentile": 29.56, "90th_percentile": 29.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 23.27, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.27, "10th_percentile": 23.27, "90th_percentile": 23.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 23.27, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.27, "10th_percentile": 23.27, "90th_percentile": 23.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 44.08, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 44.08, "10th_percentile": 44.08, "90th_percentile": 44.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 39.27, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 39.27, "10th_percentile": 39.27, "90th_percentile": 39.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 25.14, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 25.14, "10th_percentile": 25.14, "90th_percentile": 25.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 53.21, "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": 53.21, "10th_percentile": 53.21, "90th_percentile": 53.21, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 16.32, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.32, "10th_percentile": 16.32, "90th_percentile": 16.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 43.66, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.66, "10th_percentile": 43.66, "90th_percentile": 43.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 82.85, "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 $82.85 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 82.85, "10th_percentile": 82.85, "90th_percentile": 82.85, "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 $82.85 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 52.2, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $52.20 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 52.2, "10th_percentile": 52.2, "90th_percentile": 52.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $52.20 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 62.14, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 62.14, "10th_percentile": 62.14, "90th_percentile": 62.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 58.0, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 58.0, "10th_percentile": 58.0, "90th_percentile": 58.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 60.48, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 60.48, "10th_percentile": 60.48, "90th_percentile": 60.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 25.6, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.6, "10th_percentile": 25.6, "90th_percentile": 25.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 82.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 82.85, "10th_percentile": 82.85, "90th_percentile": 82.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 41.43, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 41.43, "10th_percentile": 41.43, "90th_percentile": 41.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 82.85, "10th_percentile": 82.85, "90th_percentile": 82.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 82.85, "10th_percentile": 82.85, "90th_percentile": 82.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 29.56, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.56, "10th_percentile": 29.56, "90th_percentile": 29.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 32.27, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.27, "10th_percentile": 32.27, "90th_percentile": 32.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 29.41, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 29.41, "10th_percentile": 29.41, "90th_percentile": 29.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 43.5, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.5, "10th_percentile": 43.5, "90th_percentile": 43.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 28.5, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 28.5, "10th_percentile": 28.5, "90th_percentile": 28.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 40.35, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40.35, "10th_percentile": 40.35, "90th_percentile": 40.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 15.99, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 15.99, "10th_percentile": 15.99, "90th_percentile": 15.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 24.43, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.43, "10th_percentile": 24.43, "90th_percentile": 24.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 66.28, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 66.28, "10th_percentile": 66.28, "90th_percentile": 66.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" } ] } ] }, { "description": "ADHESIVE REINF STPL LN GEL PERI-STRIPS DRY", "code_information": [ { "code": "SUP-114877", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 12.43, "maximum": 64.39, "setting": "outpatient", "gross_charge": 64.39, "discounted_cash": 45.07, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 64.39, "10th_percentile": 64.39, "90th_percentile": 64.39, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 64.39, "10th_percentile": 64.39, "90th_percentile": 64.39, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 64.39, "10th_percentile": 64.39, "90th_percentile": 64.39, "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": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 18.09, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.09, "10th_percentile": 18.09, "90th_percentile": 18.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 18.09, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.09, "10th_percentile": 18.09, "90th_percentile": 18.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 25.08, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 25.08, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 22.97, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.97, "10th_percentile": 22.97, "90th_percentile": 22.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 22.97, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.97, "10th_percentile": 22.97, "90th_percentile": 22.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 22.86, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 22.86, "10th_percentile": 22.86, "90th_percentile": 22.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 22.15, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 22.15, "10th_percentile": 22.15, "90th_percentile": 22.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 31.36, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.36, "10th_percentile": 31.36, "90th_percentile": 31.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 12.43, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 12.43, "10th_percentile": 12.43, "90th_percentile": 12.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 33.8, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.8, "10th_percentile": 33.8, "90th_percentile": 33.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 64.39, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 64.39, "10th_percentile": 64.39, "90th_percentile": 64.39, "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 18.99, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.99, "10th_percentile": 18.99, "90th_percentile": 18.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 32.2, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 32.2, "10th_percentile": 32.2, "90th_percentile": 32.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 45.07, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 45.07, "10th_percentile": 45.07, "90th_percentile": 45.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 47.0, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 47.0, "10th_percentile": 47.0, "90th_percentile": 47.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 33.93, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.93, "10th_percentile": 33.93, "90th_percentile": 33.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 19.54, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 19.54, "10th_percentile": 19.54, "90th_percentile": 19.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 40.57, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $40.57 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 40.57, "10th_percentile": 40.57, "90th_percentile": 40.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $40.57 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 64.39, "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 $64.39 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 64.39, "10th_percentile": 64.39, "90th_percentile": 64.39, "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 $64.39 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 12.68, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.68, "10th_percentile": 12.68, "90th_percentile": 12.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 51.51, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 51.51, "10th_percentile": 51.51, "90th_percentile": 51.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 19.9, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.9, "10th_percentile": 19.9, "90th_percentile": 19.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 48.29, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 48.29, "10th_percentile": 48.29, "90th_percentile": 48.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 34.26, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 34.26, "10th_percentile": 34.26, "90th_percentile": 34.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 41.36, "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": 41.36, "10th_percentile": 41.36, "90th_percentile": 41.36, "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": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 30.52, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 30.52, "10th_percentile": 30.52, "90th_percentile": 30.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "description": "ADHESIVE SKIN AFFIX SURG TOPICAL .4 ML MSC091040Z - (DUP USE PS 381475)", "code_information": [ { "code": "SUP-347688", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 10.29, "maximum": 53.31, "setting": "outpatient", "gross_charge": 53.31, "discounted_cash": 37.32, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 53.31, "10th_percentile": 53.31, "90th_percentile": 53.31, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 53.31, "10th_percentile": 53.31, "90th_percentile": 53.31, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 53.31, "10th_percentile": 53.31, "90th_percentile": 53.31, "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": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 14.97, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.97, "10th_percentile": 14.97, "90th_percentile": 14.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 14.97, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.97, "10th_percentile": 14.97, "90th_percentile": 14.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 20.76, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.76, "10th_percentile": 20.76, "90th_percentile": 20.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 20.76, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.76, "10th_percentile": 20.76, "90th_percentile": 20.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 19.02, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.02, "10th_percentile": 19.02, "90th_percentile": 19.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 19.02, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.02, "10th_percentile": 19.02, "90th_percentile": 19.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 18.93, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% 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; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 18.34, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 18.34, "10th_percentile": 18.34, "90th_percentile": 18.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 25.96, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.96, "10th_percentile": 25.96, "90th_percentile": 25.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 10.29, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 10.29, "10th_percentile": 10.29, "90th_percentile": 10.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 27.99, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.99, "10th_percentile": 27.99, "90th_percentile": 27.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 53.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 53.31, "10th_percentile": 53.31, "90th_percentile": 53.31, "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 15.72, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.72, "10th_percentile": 15.72, "90th_percentile": 15.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 26.66, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 26.66, "10th_percentile": 26.66, "90th_percentile": 26.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 37.32, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 37.32, "10th_percentile": 37.32, "90th_percentile": 37.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 38.92, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 38.92, "10th_percentile": 38.92, "90th_percentile": 38.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 28.09, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.09, "10th_percentile": 28.09, "90th_percentile": 28.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 16.18, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 16.18, "10th_percentile": 16.18, "90th_percentile": 16.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 33.59, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $33.59 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 33.59, "10th_percentile": 33.59, "90th_percentile": 33.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $33.59 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 53.31, "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 $53.31 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 53.31, "10th_percentile": 53.31, "90th_percentile": 53.31, "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 $53.31 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 10.5, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 42.65, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 42.65, "10th_percentile": 42.65, "90th_percentile": 42.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 16.47, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.47, "10th_percentile": 16.47, "90th_percentile": 16.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 39.98, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 39.98, "10th_percentile": 39.98, "90th_percentile": 39.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 28.36, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 28.36, "10th_percentile": 28.36, "90th_percentile": 28.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 34.24, "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": 34.24, "10th_percentile": 34.24, "90th_percentile": 34.24, "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": "NWR UHC CORE", "standard_charge_dollar": 25.27, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 25.27, "10th_percentile": 25.27, "90th_percentile": 25.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "description": "ADHESIVE SKNCLS 2 OCTYL CYNCRLT DRMBND V", "code_information": [ { "code": "SUP-347860", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 13.93, "maximum": 72.2, "setting": "outpatient", "gross_charge": 72.2, "discounted_cash": 50.54, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 72.2, "10th_percentile": 72.2, "90th_percentile": 72.2, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 72.2, "10th_percentile": 72.2, "90th_percentile": 72.2, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 72.2, "10th_percentile": 72.2, "90th_percentile": 72.2, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 28.12, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.12, "10th_percentile": 28.12, "90th_percentile": 28.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 28.12, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.12, "10th_percentile": 28.12, "90th_percentile": 28.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 25.76, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.76, "10th_percentile": 25.76, "90th_percentile": 25.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 25.76, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.76, "10th_percentile": 25.76, "90th_percentile": 25.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 20.28, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.28, "10th_percentile": 20.28, "90th_percentile": 20.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 20.28, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.28, "10th_percentile": 20.28, "90th_percentile": 20.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 35.16, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.16, "10th_percentile": 35.16, "90th_percentile": 35.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 13.93, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 13.93, "10th_percentile": 13.93, "90th_percentile": 13.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 37.91, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.91, "10th_percentile": 37.91, "90th_percentile": 37.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 25.63, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 25.63, "10th_percentile": 25.63, "90th_percentile": 25.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 24.84, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 24.84, "10th_percentile": 24.84, "90th_percentile": 24.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 38.41, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 38.41, "10th_percentile": 38.41, "90th_percentile": 38.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 34.22, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 34.22, "10th_percentile": 34.22, "90th_percentile": 34.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 21.91, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 21.91, "10th_percentile": 21.91, "90th_percentile": 21.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 46.37, "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": 46.37, "10th_percentile": 46.37, "90th_percentile": 46.37, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 14.22, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.22, "10th_percentile": 14.22, "90th_percentile": 14.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 57.76, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 57.76, "10th_percentile": 57.76, "90th_percentile": 57.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 38.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.05, "10th_percentile": 38.05, "90th_percentile": 38.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 72.2, "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 $72.20 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 72.2, "10th_percentile": 72.2, "90th_percentile": 72.2, "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 $72.20 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 45.49, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $45.49 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 45.49, "10th_percentile": 45.49, "90th_percentile": 45.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $45.49 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 21.29, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.29, "10th_percentile": 21.29, "90th_percentile": 21.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 54.15, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 54.15, "10th_percentile": 54.15, "90th_percentile": 54.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 50.54, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 50.54, "10th_percentile": 50.54, "90th_percentile": 50.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 52.71, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 52.71, "10th_percentile": 52.71, "90th_percentile": 52.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 22.31, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.31, "10th_percentile": 22.31, "90th_percentile": 22.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 72.2, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 72.2, "10th_percentile": 72.2, "90th_percentile": 72.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 36.1, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 36.1, "10th_percentile": 36.1, "90th_percentile": 36.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" } ] } ] }, { "description": "ADHESIVE TOPICAL SKIN HISTOACRYL 0.5ML", "code_information": [ { "code": "SUP-360288", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 26.91, "maximum": 139.41, "setting": "outpatient", "gross_charge": 139.41, "discounted_cash": 97.59, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 139.41, "10th_percentile": 139.41, "90th_percentile": 139.41, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 139.41, "10th_percentile": 139.41, "90th_percentile": 139.41, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 139.41, "10th_percentile": 139.41, "90th_percentile": 139.41, "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": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 39.16, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 39.16, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 54.3, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 54.3, "10th_percentile": 54.3, "90th_percentile": 54.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 54.3, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 54.3, "10th_percentile": 54.3, "90th_percentile": 54.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 49.74, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 49.74, "10th_percentile": 49.74, "90th_percentile": 49.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 49.74, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 49.74, "10th_percentile": 49.74, "90th_percentile": 49.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 49.49, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 49.49, "10th_percentile": 49.49, "90th_percentile": 49.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 47.96, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 47.96, "10th_percentile": 47.96, "90th_percentile": 47.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 67.89, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.89, "10th_percentile": 67.89, "90th_percentile": 67.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 26.91, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 26.91, "10th_percentile": 26.91, "90th_percentile": 26.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 73.19, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 73.19, "10th_percentile": 73.19, "90th_percentile": 73.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 139.41, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 139.41, "10th_percentile": 139.41, "90th_percentile": 139.41, "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 41.11, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41.11, "10th_percentile": 41.11, "90th_percentile": 41.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 69.71, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 69.71, "10th_percentile": 69.71, "90th_percentile": 69.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 97.59, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 97.59, "10th_percentile": 97.59, "90th_percentile": 97.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 101.77, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 101.77, "10th_percentile": 101.77, "90th_percentile": 101.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 73.47, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 73.47, "10th_percentile": 73.47, "90th_percentile": 73.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 42.31, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 42.31, "10th_percentile": 42.31, "90th_percentile": 42.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 87.83, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $87.83 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 87.83, "10th_percentile": 87.83, "90th_percentile": 87.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $87.83 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 139.41, "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 $139.41 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 139.41, "10th_percentile": 139.41, "90th_percentile": 139.41, "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 $139.41 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 27.46, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.46, "10th_percentile": 27.46, "90th_percentile": 27.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 111.53, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 111.53, "10th_percentile": 111.53, "90th_percentile": 111.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 43.08, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.08, "10th_percentile": 43.08, "90th_percentile": 43.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 104.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 104.56, "10th_percentile": 104.56, "90th_percentile": 104.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 74.17, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 74.17, "10th_percentile": 74.17, "90th_percentile": 74.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 89.54, "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": 89.54, "10th_percentile": 89.54, "90th_percentile": 89.54, "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": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 66.08, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 66.08, "10th_percentile": 66.08, "90th_percentile": 66.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "description": "ADMIRAL IN.PACT 6X250MMX130CM", "code_information": [ { "code": "SUP-334753", "type": "CDM" }, { "code": "C2623", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 1772.89, "maximum": 9185.95, "setting": "outpatient", "gross_charge": 9185.95, "discounted_cash": 6430.16, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 9185.95, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9185.95, "10th_percentile": 9185.95, "90th_percentile": 9185.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 4473.56, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4473.56, "10th_percentile": 4473.56, "90th_percentile": 4473.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 3159.97, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 3159.97, "10th_percentile": 3159.97, "90th_percentile": 3159.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 4822.62, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4822.62, "10th_percentile": 4822.62, "90th_percentile": 4822.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 3261.01, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 3261.01, "10th_percentile": 3261.01, "90th_percentile": 3261.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 1772.89, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1772.89, "10th_percentile": 1772.89, "90th_percentile": 1772.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 3277.55, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3277.55, "10th_percentile": 3277.55, "90th_percentile": 3277.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 3114.04, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3114.04, "10th_percentile": 3114.04, "90th_percentile": 3114.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 7348.76, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 7348.76, "10th_percentile": 7348.76, "90th_percentile": 7348.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 3277.55, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3277.55, "10th_percentile": 3277.55, "90th_percentile": 3277.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 9185.95, "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 $9,185.95 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 9185.95, "10th_percentile": 9185.95, "90th_percentile": 9185.95, "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 $9,185.95 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": "NWR BCBS PPO", "standard_charge_dollar": 3114.04, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3114.04, "10th_percentile": 3114.04, "90th_percentile": 3114.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 4886.93, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 4886.93, "10th_percentile": 4886.93, "90th_percentile": 4886.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 1809.63, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1809.63, "10th_percentile": 1809.63, "90th_percentile": 1809.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 6889.46, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 6889.46, "10th_percentile": 6889.46, "90th_percentile": 6889.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 2838.46, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2838.46, "10th_percentile": 2838.46, "90th_percentile": 2838.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 6430.17, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 6430.17, "10th_percentile": 6430.17, "90th_percentile": 6430.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 6705.74, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 6705.74, "10th_percentile": 6705.74, "90th_percentile": 6705.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 4592.98, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 4592.98, "10th_percentile": 4592.98, "90th_percentile": 4592.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 2787.94, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 2787.94, "10th_percentile": 2787.94, "90th_percentile": 2787.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 5787.15, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $5,787.15 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 5787.15, "10th_percentile": 5787.15, "90th_percentile": 5787.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $5,787.15 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 5900.14, "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": 5900.14, "10th_percentile": 5900.14, "90th_percentile": 5900.14, "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": "NWR UHC CORE", "standard_charge_dollar": 4354.14, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 4354.14, "10th_percentile": 4354.14, "90th_percentile": 4354.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 4841.0, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4841.0, "10th_percentile": 4841.0, "90th_percentile": 4841.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4390.88, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4390.88, "10th_percentile": 4390.88, "90th_percentile": 4390.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4390.88, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4390.88, "10th_percentile": 4390.88, "90th_percentile": 4390.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4390.88, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4390.88, "10th_percentile": 4390.88, "90th_percentile": 4390.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9185.95, "10th_percentile": 9185.95, "90th_percentile": 9185.95, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9185.95, "10th_percentile": 9185.95, "90th_percentile": 9185.95, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $9,185.95 @ 12.5% = $1,148.24 due to $0.00 Claim Price", "median_amount": 1148.24, "10th_percentile": 1148.24, "90th_percentile": 1148.24, "count": "0", "methodology": "other", "additional_payer_notes": "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: $9,185.95 @ 12.5% = $1,148.24 due to $0.00 Claim Price" } ] } ] }, { "description": "ADPT FEM OFST REV 3MM", "code_information": [ { "code": "SUP-143568", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1449.79, "maximum": 7511.88, "setting": "outpatient", "gross_charge": 7511.88, "discounted_cash": 5258.32, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 2321.17, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.6, "10th_percentile": 1188.6, "90th_percentile": 1188.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 2546.53, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2546.53, "10th_percentile": 2546.53, "90th_percentile": 2546.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 3958.76, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2627.73, "10th_percentile": 2627.73, "90th_percentile": 2627.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 3996.32, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 3996.32, "10th_percentile": 3996.32, "90th_percentile": 3996.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 4732.48, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $4,732.48 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 4732.48, "10th_percentile": 4732.48, "90th_percentile": 4732.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $4,732.48 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 1479.84, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1479.84, "10th_percentile": 1479.84, "90th_percentile": 1479.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 7511.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7511.88, "10th_percentile": 7511.88, "90th_percentile": 7511.88, "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": "NWR HFN PPO", "standard_charge_dollar": 5483.67, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 5483.67, "10th_percentile": 5483.67, "90th_percentile": 5483.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 5633.91, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 5633.91, "10th_percentile": 5633.91, "90th_percentile": 5633.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 4824.88, "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": 4824.88, "10th_percentile": 4824.88, "90th_percentile": 4824.88, "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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 5258.32, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 5258.32, "10th_percentile": 5258.32, "90th_percentile": 5258.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 2279.86, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 2279.86, "10th_percentile": 2279.86, "90th_percentile": 2279.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 3560.63, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 3560.63, "10th_percentile": 3560.63, "90th_percentile": 3560.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 3755.94, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 3755.94, "10th_percentile": 3755.94, "90th_percentile": 3755.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $7,511.88 @ 12.5% = $938.99 due to $0.00 Claim Price", "median_amount": 938.99, "10th_percentile": 938.99, "90th_percentile": 938.99, "count": "0", "methodology": "other", "additional_payer_notes": "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: $7,511.88 @ 12.5% = $938.99 due to $0.00 Claim Price" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 1449.79, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1001.28, "10th_percentile": 1001.28, "90th_percentile": 1001.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3590.68, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3590.68, "10th_percentile": 3590.68, "90th_percentile": 3590.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3590.68, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3590.68, "10th_percentile": 3590.68, "90th_percentile": 3590.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3590.68, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3590.68, "10th_percentile": 3590.68, "90th_percentile": 3590.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 2546.53, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2546.53, "10th_percentile": 2546.53, "90th_percentile": 2546.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 2680.24, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2680.24, "10th_percentile": 2680.24, "90th_percentile": 2680.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 2680.24, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2680.24, "10th_percentile": 2680.24, "90th_percentile": 2680.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 2193.47, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2193.47, "10th_percentile": 2193.47, "90th_percentile": 2193.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 2193.47, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2193.47, "10th_percentile": 2193.47, "90th_percentile": 2193.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 7511.88, "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 $7,511.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 7511.88, "10th_percentile": 7511.88, "90th_percentile": 7511.88, "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 $7,511.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 2584.09, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 2584.09, "10th_percentile": 2584.09, "90th_percentile": 2584.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 2666.72, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 2666.72, "10th_percentile": 2666.72, "90th_percentile": 2666.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 6009.5, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 6009.5, "10th_percentile": 6009.5, "90th_percentile": 6009.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7511.88, "10th_percentile": 7511.88, "90th_percentile": 7511.88, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7511.88, "10th_percentile": 7511.88, "90th_percentile": 7511.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "ADPT HEAD FEM ENDOPROS VERSYS +10.5MM TIV", "code_information": [ { "code": "SUP-349723", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 82.85, "maximum": 429.25, "setting": "outpatient", "gross_charge": 429.25, "discounted_cash": 300.47, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 82.85, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1001.28, "10th_percentile": 1001.28, "90th_percentile": 1001.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 132.64, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.6, "10th_percentile": 1188.6, "90th_percentile": 1188.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 205.18, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 205.18, "10th_percentile": 205.18, "90th_percentile": 205.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 205.18, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 205.18, "10th_percentile": 205.18, "90th_percentile": 205.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 205.18, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 205.18, "10th_percentile": 205.18, "90th_percentile": 205.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 153.16, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 153.16, "10th_percentile": 153.16, "90th_percentile": 153.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 153.16, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 153.16, "10th_percentile": 153.16, "90th_percentile": 153.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 145.52, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 145.52, "10th_percentile": 145.52, "90th_percentile": 145.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 145.52, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 145.52, "10th_percentile": 145.52, "90th_percentile": 145.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 226.21, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2627.73, "10th_percentile": 2627.73, "90th_percentile": 2627.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 228.36, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 228.36, "10th_percentile": 228.36, "90th_percentile": 228.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 429.25, "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 $429.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 429.25, "10th_percentile": 429.25, "90th_percentile": 429.25, "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 $429.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 270.43, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $270.43 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 270.43, "10th_percentile": 270.43, "90th_percentile": 270.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $270.43 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 84.56, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 84.56, "10th_percentile": 84.56, "90th_percentile": 84.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 429.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 429.25, "10th_percentile": 429.25, "90th_percentile": 429.25, "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": "NWR HFN PPO", "standard_charge_dollar": 313.35, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 313.35, "10th_percentile": 313.35, "90th_percentile": 313.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 321.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 321.94, "10th_percentile": 321.94, "90th_percentile": 321.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 275.71, "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": 275.71, "10th_percentile": 275.71, "90th_percentile": 275.71, "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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 300.48, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 300.48, "10th_percentile": 300.48, "90th_percentile": 300.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 130.28, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 130.28, "10th_percentile": 130.28, "90th_percentile": 130.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 343.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 343.4, "10th_percentile": 343.4, "90th_percentile": 343.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 203.46, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 203.46, "10th_percentile": 203.46, "90th_percentile": 203.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 214.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 214.63, "10th_percentile": 214.63, "90th_percentile": 214.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 429.25, "10th_percentile": 429.25, "90th_percentile": 429.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 429.25, "10th_percentile": 429.25, "90th_percentile": 429.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $429.25 @ 12.5% = $53.66 due to $0.00 Claim Price", "median_amount": 53.66, "10th_percentile": 53.66, "90th_percentile": 53.66, "count": "0", "methodology": "other", "additional_payer_notes": "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: $429.25 @ 12.5% = $53.66 due to $0.00 Claim Price" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 125.34, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 125.34, "10th_percentile": 125.34, "90th_percentile": 125.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 125.34, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 125.34, "10th_percentile": 125.34, "90th_percentile": 125.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 152.38, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 152.38, "10th_percentile": 152.38, "90th_percentile": 152.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 147.66, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 147.66, "10th_percentile": 147.66, "90th_percentile": 147.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" } ] } ] }, { "description": "ADPT IV ANGIO AIRLSS ROT M TO", "code_information": [ { "code": "SUP-306785", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 1.62, "maximum": 8.37, "setting": "outpatient", "gross_charge": 8.37, "discounted_cash": 5.86, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.37, "10th_percentile": 8.37, "90th_percentile": 8.37, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.37, "10th_percentile": 8.37, "90th_percentile": 8.37, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.37, "10th_percentile": 8.37, "90th_percentile": 8.37, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 3.26, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.26, "10th_percentile": 3.26, "90th_percentile": 3.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 3.26, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.26, "10th_percentile": 3.26, "90th_percentile": 3.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 2.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 2.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2.35, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.35, "10th_percentile": 2.35, "90th_percentile": 2.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.35, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.35, "10th_percentile": 2.35, "90th_percentile": 2.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 4.08, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.08, "10th_percentile": 4.08, "90th_percentile": 4.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 1.62, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1.62, "10th_percentile": 1.62, "90th_percentile": 1.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 4.39, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.39, "10th_percentile": 4.39, "90th_percentile": 4.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 2.97, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 2.97, "10th_percentile": 2.97, "90th_percentile": 2.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 2.88, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% 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; 34.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 4.45, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 4.45, "10th_percentile": 4.45, "90th_percentile": 4.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 3.97, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 3.97, "10th_percentile": 3.97, "90th_percentile": 3.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 2.54, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 2.54, "10th_percentile": 2.54, "90th_percentile": 2.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 1.65, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 4.41, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.41, "10th_percentile": 4.41, "90th_percentile": 4.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 8.37, "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 $8.37 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8.37, "10th_percentile": 8.37, "90th_percentile": 8.37, "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 $8.37 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 5.27, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $5.27 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 5.27, "10th_percentile": 5.27, "90th_percentile": 5.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $5.27 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.47, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 6.28, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 6.28, "10th_percentile": 6.28, "90th_percentile": 6.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 5.86, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 5.86, "10th_percentile": 5.86, "90th_percentile": 5.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 6.11, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% 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; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 2.59, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 8.37, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8.37, "10th_percentile": 8.37, "90th_percentile": 8.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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" } ] } ] }, { "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": 699.28, "maximum": 3623.22, "setting": "outpatient", "gross_charge": 3623.22, "discounted_cash": 2536.25, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 699.28, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1001.28, "10th_percentile": 1001.28, "90th_percentile": 1001.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 1119.57, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.6, "10th_percentile": 1188.6, "90th_percentile": 1188.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1731.9, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1731.9, "10th_percentile": 1731.9, "90th_percentile": 1731.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1731.9, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1731.9, "10th_percentile": 1731.9, "90th_percentile": 1731.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1731.9, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1731.9, "10th_percentile": 1731.9, "90th_percentile": 1731.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 1292.76, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1292.76, "10th_percentile": 1292.76, "90th_percentile": 1292.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1292.76, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1292.76, "10th_percentile": 1292.76, "90th_percentile": 1292.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1228.27, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1228.27, "10th_percentile": 1228.27, "90th_percentile": 1228.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1228.27, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1228.27, "10th_percentile": 1228.27, "90th_percentile": 1228.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 1057.98, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1057.98, "10th_percentile": 1057.98, "90th_percentile": 1057.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1057.98, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1057.98, "10th_percentile": 1057.98, "90th_percentile": 1057.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1909.44, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2627.73, "10th_percentile": 2627.73, "90th_percentile": 2627.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3623.22, "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 $3,623.22 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3623.22, "10th_percentile": 3623.22, "90th_percentile": 3623.22, "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 $3,623.22 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 2282.63, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,282.63 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 2282.63, "10th_percentile": 2282.63, "90th_percentile": 2282.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,282.63 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 2327.19, "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": 2327.19, "10th_percentile": 2327.19, "90th_percentile": 2327.19, "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": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 1717.41, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1717.41, "10th_percentile": 1717.41, "90th_percentile": 1717.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2536.25, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 2536.25, "10th_percentile": 2536.25, "90th_percentile": 2536.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1927.55, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1927.55, "10th_percentile": 1927.55, "90th_percentile": 1927.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 2898.58, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2898.58, "10th_percentile": 2898.58, "90th_percentile": 2898.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 713.77, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 713.77, "10th_percentile": 713.77, "90th_percentile": 713.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1286.24, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1286.24, "10th_percentile": 1286.24, "90th_percentile": 1286.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2717.42, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 2717.42, "10th_percentile": 2717.42, "90th_percentile": 2717.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 1246.39, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1246.39, "10th_percentile": 1246.39, "90th_percentile": 1246.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 3623.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3623.22, "10th_percentile": 3623.22, "90th_percentile": 3623.22, "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": "NWR HFN PPO", "standard_charge_dollar": 2644.95, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 2644.95, "10th_percentile": 2644.95, "90th_percentile": 2644.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 1099.65, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 1099.65, "10th_percentile": 1099.65, "90th_percentile": 1099.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1811.61, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1811.61, "10th_percentile": 1811.61, "90th_percentile": 1811.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3623.22, "10th_percentile": 3623.22, "90th_percentile": 3623.22, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3623.22, "10th_percentile": 3623.22, "90th_percentile": 3623.22, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $3,623.22 @ 12.5% = $452.90 due to $0.00 Claim Price", "median_amount": 452.9, "10th_percentile": 452.9, "90th_percentile": 452.9, "count": "0", "methodology": "other", "additional_payer_notes": "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: $3,623.22 @ 12.5% = $452.90 due to $0.00 Claim Price" } ] } ] }, { "description": "ADPT OFST DURAC STD 6MM COCR", "code_information": [ { "code": "SUP-58294", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 720.26, "maximum": 3731.9, "setting": "outpatient", "gross_charge": 3731.9, "discounted_cash": 2612.33, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 720.26, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1001.28, "10th_percentile": 1001.28, "90th_percentile": 1001.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 1153.16, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.6, "10th_percentile": 1188.6, "90th_percentile": 1188.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1783.85, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1783.85, "10th_percentile": 1783.85, "90th_percentile": 1783.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1783.85, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1783.85, "10th_percentile": 1783.85, "90th_percentile": 1783.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1783.85, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1783.85, "10th_percentile": 1783.85, "90th_percentile": 1783.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1265.11, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1265.11, "10th_percentile": 1265.11, "90th_percentile": 1265.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1265.11, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1265.11, "10th_percentile": 1265.11, "90th_percentile": 1265.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 1331.54, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1331.54, "10th_percentile": 1331.54, "90th_percentile": 1331.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1331.54, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1331.54, "10th_percentile": 1331.54, "90th_percentile": 1331.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1089.71, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1089.71, "10th_percentile": 1089.71, "90th_percentile": 1089.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 1089.71, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1089.71, "10th_percentile": 1089.71, "90th_percentile": 1089.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 2351.1, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,351.10 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 2351.1, "10th_percentile": 2351.1, "90th_percentile": 2351.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,351.10 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3731.9, "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 $3,731.90 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3731.9, "10th_percentile": 3731.9, "90th_percentile": 3731.9, "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 $3,731.90 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 3731.9, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3731.9, "10th_percentile": 3731.9, "90th_percentile": 3731.9, "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": "NWR HFN PPO", "standard_charge_dollar": 2724.29, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 2724.29, "10th_percentile": 2724.29, "90th_percentile": 2724.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 1768.92, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1768.92, "10th_percentile": 1768.92, "90th_percentile": 1768.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2612.33, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 2612.33, "10th_percentile": 2612.33, "90th_percentile": 2612.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 1132.63, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 1132.63, "10th_percentile": 1132.63, "90th_percentile": 1132.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1865.95, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1865.95, "10th_percentile": 1865.95, "90th_percentile": 1865.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1985.37, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1985.37, "10th_percentile": 1985.37, "90th_percentile": 1985.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2798.93, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 2798.93, "10th_percentile": 2798.93, "90th_percentile": 2798.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 1283.77, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1283.77, "10th_percentile": 1283.77, "90th_percentile": 1283.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 735.18, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 735.18, "10th_percentile": 735.18, "90th_percentile": 735.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1324.82, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1324.82, "10th_percentile": 1324.82, "90th_percentile": 1324.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 2397.0, "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": 2397.0, "10th_percentile": 2397.0, "90th_percentile": 2397.0, "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": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 2985.52, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2985.52, "10th_percentile": 2985.52, "90th_percentile": 2985.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1966.71, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2627.73, "10th_percentile": 2627.73, "90th_percentile": 2627.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3731.9, "10th_percentile": 3731.9, "90th_percentile": 3731.9, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3731.9, "10th_percentile": 3731.9, "90th_percentile": 3731.9, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $3,731.90 @ 12.5% = $466.49 due to $0.00 Claim Price", "median_amount": 466.49, "10th_percentile": 466.49, "90th_percentile": 466.49, "count": "0", "methodology": "other", "additional_payer_notes": "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: $3,731.90 @ 12.5% = $466.49 due to $0.00 Claim Price" } ] } ] }, { "description": "ADPT PERF 0.25IN STRL", "code_information": [ { "code": "SUP-153803", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 8.02, "maximum": 41.53, "setting": "outpatient", "gross_charge": 41.53, "discounted_cash": 29.07, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 41.53, "10th_percentile": 41.53, "90th_percentile": 41.53, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 41.53, "10th_percentile": 41.53, "90th_percentile": 41.53, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 41.53, "10th_percentile": 41.53, "90th_percentile": 41.53, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 16.18, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.18, "10th_percentile": 16.18, "90th_percentile": 16.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 16.18, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.18, "10th_percentile": 16.18, "90th_percentile": 16.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 14.82, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.82, "10th_percentile": 14.82, "90th_percentile": 14.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 14.82, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.82, "10th_percentile": 14.82, "90th_percentile": 14.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 11.67, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.67, "10th_percentile": 11.67, "90th_percentile": 11.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 11.67, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.67, "10th_percentile": 11.67, "90th_percentile": 11.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 20.23, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.23, "10th_percentile": 20.23, "90th_percentile": 20.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 8.02, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 8.02, "10th_percentile": 8.02, "90th_percentile": 8.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 21.8, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.8, "10th_percentile": 21.8, "90th_percentile": 21.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 14.74, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 14.74, "10th_percentile": 14.74, "90th_percentile": 14.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 14.29, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 14.29, "10th_percentile": 14.29, "90th_percentile": 14.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 22.09, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 22.09, "10th_percentile": 22.09, "90th_percentile": 22.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 19.69, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 19.69, "10th_percentile": 19.69, "90th_percentile": 19.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 12.6, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 12.6, "10th_percentile": 12.6, "90th_percentile": 12.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 26.67, "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": 26.67, "10th_percentile": 26.67, "90th_percentile": 26.67, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 8.18, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.18, "10th_percentile": 8.18, "90th_percentile": 8.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 33.22, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 33.22, "10th_percentile": 33.22, "90th_percentile": 33.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 21.89, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.89, "10th_percentile": 21.89, "90th_percentile": 21.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 41.53, "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 $41.53 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 41.53, "10th_percentile": 41.53, "90th_percentile": 41.53, "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 $41.53 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 26.16, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $26.16 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 26.16, "10th_percentile": 26.16, "90th_percentile": 26.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $26.16 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 12.25, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 31.15, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 31.15, "10th_percentile": 31.15, "90th_percentile": 31.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 29.07, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 29.07, "10th_percentile": 29.07, "90th_percentile": 29.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 30.32, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 30.32, "10th_percentile": 30.32, "90th_percentile": 30.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 12.83, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.83, "10th_percentile": 12.83, "90th_percentile": 12.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 41.53, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 41.53, "10th_percentile": 41.53, "90th_percentile": 41.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 20.77, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 20.77, "10th_percentile": 20.77, "90th_percentile": 20.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" } ] } ] }, { "description": "ADPT SLV ADJ FEM NK MOD UNITRX PCA +10MM", "code_information": [ { "code": "SUP-129129", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 41.42, "maximum": 214.63, "setting": "outpatient", "gross_charge": 214.63, "discounted_cash": 150.24, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 41.42, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1001.28, "10th_percentile": 1001.28, "90th_percentile": 1001.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 66.32, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.6, "10th_percentile": 1188.6, "90th_percentile": 1188.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 102.59, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.59, "10th_percentile": 102.59, "90th_percentile": 102.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 102.59, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.59, "10th_percentile": 102.59, "90th_percentile": 102.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 102.59, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.59, "10th_percentile": 102.59, "90th_percentile": 102.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 76.58, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.58, "10th_percentile": 76.58, "90th_percentile": 76.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 76.58, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.58, "10th_percentile": 76.58, "90th_percentile": 76.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 72.76, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.76, "10th_percentile": 72.76, "90th_percentile": 72.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 72.76, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.76, "10th_percentile": 72.76, "90th_percentile": 72.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 62.67, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.67, "10th_percentile": 62.67, "90th_percentile": 62.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 62.67, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.67, "10th_percentile": 62.67, "90th_percentile": 62.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 113.11, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2627.73, "10th_percentile": 2627.73, "90th_percentile": 2627.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 214.63, "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 $214.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 214.63, "10th_percentile": 214.63, "90th_percentile": 214.63, "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 $214.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 135.22, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $135.22 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 135.22, "10th_percentile": 135.22, "90th_percentile": 135.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $135.22 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 137.86, "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": 137.86, "10th_percentile": 137.86, "90th_percentile": 137.86, "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": "NWR UHC CORE", "standard_charge_dollar": 101.73, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 101.73, "10th_percentile": 101.73, "90th_percentile": 101.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 150.24, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 150.24, "10th_percentile": 150.24, "90th_percentile": 150.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 114.18, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 114.18, "10th_percentile": 114.18, "90th_percentile": 114.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 171.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 171.7, "10th_percentile": 171.7, "90th_percentile": 171.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 42.28, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.28, "10th_percentile": 42.28, "90th_percentile": 42.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 76.19, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 76.19, "10th_percentile": 76.19, "90th_percentile": 76.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 160.97, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 160.97, "10th_percentile": 160.97, "90th_percentile": 160.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 73.83, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 73.83, "10th_percentile": 73.83, "90th_percentile": 73.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 214.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 214.63, "10th_percentile": 214.63, "90th_percentile": 214.63, "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": "NWR HFN PPO", "standard_charge_dollar": 156.68, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 156.68, "10th_percentile": 156.68, "90th_percentile": 156.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 65.14, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% 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; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 107.32, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 107.32, "10th_percentile": 107.32, "90th_percentile": 107.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 214.63, "10th_percentile": 214.63, "90th_percentile": 214.63, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 214.63, "10th_percentile": 214.63, "90th_percentile": 214.63, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $214.63 @ 12.5% = $26.83 due to $0.00 Claim Price", "median_amount": 26.83, "10th_percentile": 26.83, "90th_percentile": 26.83, "count": "0", "methodology": "other", "additional_payer_notes": "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: $214.63 @ 12.5% = $26.83 due to $0.00 Claim Price" } ] } ] }, { "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": 40.22, "maximum": 208.38, "setting": "outpatient", "gross_charge": 208.38, "discounted_cash": 145.87, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 40.22, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1001.28, "10th_percentile": 1001.28, "90th_percentile": 1001.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 64.39, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.6, "10th_percentile": 1188.6, "90th_percentile": 1188.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 99.61, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 99.61, "10th_percentile": 99.61, "90th_percentile": 99.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 99.61, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 99.61, "10th_percentile": 99.61, "90th_percentile": 99.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 99.61, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 99.61, "10th_percentile": 99.61, "90th_percentile": 99.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 74.35, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 74.35, "10th_percentile": 74.35, "90th_percentile": 74.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 74.35, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 74.35, "10th_percentile": 74.35, "90th_percentile": 74.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 70.64, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.64, "10th_percentile": 70.64, "90th_percentile": 70.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 70.64, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.64, "10th_percentile": 70.64, "90th_percentile": 70.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 60.85, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.85, "10th_percentile": 60.85, "90th_percentile": 60.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 60.85, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.85, "10th_percentile": 60.85, "90th_percentile": 60.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 109.82, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2627.73, "10th_percentile": 2627.73, "90th_percentile": 2627.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 208.38, "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 $208.38 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 208.38, "10th_percentile": 208.38, "90th_percentile": 208.38, "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 $208.38 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 131.28, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $131.28 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 131.28, "10th_percentile": 131.28, "90th_percentile": 131.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $131.28 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 133.84, "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": 133.84, "10th_percentile": 133.84, "90th_percentile": 133.84, "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": "NWR UHC CORE", "standard_charge_dollar": 98.77, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 98.77, "10th_percentile": 98.77, "90th_percentile": 98.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 145.87, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 145.87, "10th_percentile": 145.87, "90th_percentile": 145.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 110.86, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 110.86, "10th_percentile": 110.86, "90th_percentile": 110.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 166.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 166.7, "10th_percentile": 166.7, "90th_percentile": 166.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 41.05, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41.05, "10th_percentile": 41.05, "90th_percentile": 41.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 73.97, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 73.97, "10th_percentile": 73.97, "90th_percentile": 73.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 156.29, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 156.29, "10th_percentile": 156.29, "90th_percentile": 156.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 71.68, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 71.68, "10th_percentile": 71.68, "90th_percentile": 71.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 208.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 208.38, "10th_percentile": 208.38, "90th_percentile": 208.38, "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": "NWR HFN PPO", "standard_charge_dollar": 152.12, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 152.12, "10th_percentile": 152.12, "90th_percentile": 152.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 63.24, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 63.24, "10th_percentile": 63.24, "90th_percentile": 63.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 104.19, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 104.19, "10th_percentile": 104.19, "90th_percentile": 104.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 208.38, "10th_percentile": 208.38, "90th_percentile": 208.38, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 208.38, "10th_percentile": 208.38, "90th_percentile": 208.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $208.38 @ 12.5% = $26.05 due to $0.00 Claim Price", "median_amount": 26.05, "10th_percentile": 26.05, "90th_percentile": 26.05, "count": "0", "methodology": "other", "additional_payer_notes": "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: $208.38 @ 12.5% = $26.05 due to $0.00 Claim Price" } ] } ] }, { "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": 96.56, "maximum": 500.29, "setting": "outpatient", "gross_charge": 500.29, "discounted_cash": 350.2, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 96.56, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1001.28, "10th_percentile": 1001.28, "90th_percentile": 1001.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 154.59, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.6, "10th_percentile": 1188.6, "90th_percentile": 1188.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 239.14, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 239.14, "10th_percentile": 239.14, "90th_percentile": 239.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 239.14, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 239.14, "10th_percentile": 239.14, "90th_percentile": 239.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 239.14, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 239.14, "10th_percentile": 239.14, "90th_percentile": 239.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 178.5, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 178.5, "10th_percentile": 178.5, "90th_percentile": 178.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 178.5, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 178.5, "10th_percentile": 178.5, "90th_percentile": 178.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 169.6, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 169.6, "10th_percentile": 169.6, "90th_percentile": 169.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 169.6, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 169.6, "10th_percentile": 169.6, "90th_percentile": 169.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 146.08, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 146.08, "10th_percentile": 146.08, "90th_percentile": 146.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 146.08, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 146.08, "10th_percentile": 146.08, "90th_percentile": 146.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 263.65, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2627.73, "10th_percentile": 2627.73, "90th_percentile": 2627.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 500.29, "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 $500.29 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 500.29, "10th_percentile": 500.29, "90th_percentile": 500.29, "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 $500.29 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 315.18, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $315.18 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 315.18, "10th_percentile": 315.18, "90th_percentile": 315.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $315.18 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 321.34, "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": 321.34, "10th_percentile": 321.34, "90th_percentile": 321.34, "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": "NWR UHC CORE", "standard_charge_dollar": 237.14, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 237.14, "10th_percentile": 237.14, "90th_percentile": 237.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 350.2, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 350.2, "10th_percentile": 350.2, "90th_percentile": 350.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 266.15, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 266.15, "10th_percentile": 266.15, "90th_percentile": 266.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 400.23, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 400.23, "10th_percentile": 400.23, "90th_percentile": 400.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 98.56, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 98.56, "10th_percentile": 98.56, "90th_percentile": 98.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 177.6, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 177.6, "10th_percentile": 177.6, "90th_percentile": 177.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 375.22, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 375.22, "10th_percentile": 375.22, "90th_percentile": 375.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 172.1, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 172.1, "10th_percentile": 172.1, "90th_percentile": 172.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 500.29, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 500.29, "10th_percentile": 500.29, "90th_percentile": 500.29, "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": "NWR HFN PPO", "standard_charge_dollar": 365.21, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 365.21, "10th_percentile": 365.21, "90th_percentile": 365.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 151.84, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 151.84, "10th_percentile": 151.84, "90th_percentile": 151.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 250.15, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 250.15, "10th_percentile": 250.15, "90th_percentile": 250.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 500.29, "10th_percentile": 500.29, "90th_percentile": 500.29, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 500.29, "10th_percentile": 500.29, "90th_percentile": 500.29, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $500.29 @ 12.5% = $62.54 due to $0.00 Claim Price", "median_amount": 62.54, "10th_percentile": 62.54, "90th_percentile": 62.54, "count": "0", "methodology": "other", "additional_payer_notes": "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: $500.29 @ 12.5% = $62.54 due to $0.00 Claim Price" } ] } ] }, { "description": "ADPTR TBE FDNG UNIV Y 20FR", "code_information": [ { "code": "SUP-301935", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 6.71, "maximum": 34.77, "setting": "outpatient", "gross_charge": 34.77, "discounted_cash": 24.34, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 16.48, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 16.48, "10th_percentile": 16.48, "90th_percentile": 16.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 22.33, "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": 22.33, "10th_percentile": 22.33, "90th_percentile": 22.33, "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": "NWR UHC HMO/PPO", "standard_charge_dollar": 18.32, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.32, "10th_percentile": 18.32, "90th_percentile": 18.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 34.77, "10th_percentile": 34.77, "90th_percentile": 34.77, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 34.77, "10th_percentile": 34.77, "90th_percentile": 34.77, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 34.77, "10th_percentile": 34.77, "90th_percentile": 34.77, "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": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 9.77, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.77, "10th_percentile": 9.77, "90th_percentile": 9.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 9.77, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.77, "10th_percentile": 9.77, "90th_percentile": 9.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 13.54, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.54, "10th_percentile": 13.54, "90th_percentile": 13.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 13.54, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.54, "10th_percentile": 13.54, "90th_percentile": 13.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 12.41, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.41, "10th_percentile": 12.41, "90th_percentile": 12.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 12.41, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.41, "10th_percentile": 12.41, "90th_percentile": 12.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 12.34, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 12.34, "10th_percentile": 12.34, "90th_percentile": 12.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 11.96, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 11.96, "10th_percentile": 11.96, "90th_percentile": 11.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 16.93, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.93, "10th_percentile": 16.93, "90th_percentile": 16.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 6.71, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 6.71, "10th_percentile": 6.71, "90th_percentile": 6.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 18.25, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.25, "10th_percentile": 18.25, "90th_percentile": 18.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 34.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 34.77, "10th_percentile": 34.77, "90th_percentile": 34.77, "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10.25, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.25, "10th_percentile": 10.25, "90th_percentile": 10.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 17.39, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 17.39, "10th_percentile": 17.39, "90th_percentile": 17.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 24.34, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 24.34, "10th_percentile": 24.34, "90th_percentile": 24.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 25.38, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 25.38, "10th_percentile": 25.38, "90th_percentile": 25.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 10.55, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 10.55, "10th_percentile": 10.55, "90th_percentile": 10.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 21.91, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $21.91 so that total pmt for all claim lines does not exceed 63% 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": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $21.91 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 34.77, "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 $34.77 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 34.77, "10th_percentile": 34.77, "90th_percentile": 34.77, "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 $34.77 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 6.85, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.85, "10th_percentile": 6.85, "90th_percentile": 6.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 27.82, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 27.82, "10th_percentile": 27.82, "90th_percentile": 27.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 10.74, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.74, "10th_percentile": 10.74, "90th_percentile": 10.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 26.08, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 26.08, "10th_percentile": 26.08, "90th_percentile": 26.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 18.5, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 18.5, "10th_percentile": 18.5, "90th_percentile": 18.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" } ] } ] }, { "description": "ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC", "code_information": [ { "code": "614", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 15596.48, "maximum": 26796.95, "setting": "inpatient", "gross_charge": 136987.5, "discounted_cash": 95891.25, "payers_information": [ { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; Inpatient Services; 50% Billed", "median_amount": 68557.0, "10th_percentile": 68557.0, "90th_percentile": 68557.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; Inpatient; 30.35% Billed", "median_amount": 41614.1, "10th_percentile": 41614.1, "90th_percentile": 41614.1, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; All IP Services; 100% Billed", "median_amount": 137114.0, "10th_percentile": 137114.0, "90th_percentile": 137114.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_percentage": 64.0, "standard_charge_algorithm": "May include reimbursement for certain add-on services.", "median_amount": 86381.82, "10th_percentile": 86381.82, "90th_percentile": 86381.82, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; IP Stop Loss 1 & 2; 64% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid $86,381.82 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_percentage": 53.1, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; Stop Loss; 53.1% 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": 72807.53, "10th_percentile": 72807.53, "90th_percentile": 72807.53, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_percentage": 34.5, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; Inpatient; 34.5% Billed", "median_amount": 47304.33, "10th_percentile": 47304.33, "90th_percentile": 47304.33, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_percentage": 36.1, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; Inpatient; 36.1% Billed", "median_amount": 49498.15, "10th_percentile": 49498.15, "90th_percentile": 49498.15, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; Stop Loss; 70% Billed", "median_amount": 95979.8, "10th_percentile": 95979.8, "90th_percentile": 95979.8, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_percentage": 73.0, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; All Inpatient Services; 73% Billed", "median_amount": 100093.22, "10th_percentile": 100093.22, "90th_percentile": 100093.22, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 71.3, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; IP Services. ADP RATE (for patient estimates only); 71.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 97762.28, "10th_percentile": 97762.28, "90th_percentile": 97762.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_percentage": 50.8, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; Inpatient; 50.8% Billed", "median_amount": 69653.91, "10th_percentile": 69653.91, "90th_percentile": 69653.91, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; Inpatient; 80% Billed", "median_amount": 109691.2, "10th_percentile": 109691.2, "90th_percentile": 109691.2, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_percentage": 19.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 26463.01, "10th_percentile": 26463.01, "90th_percentile": 26463.01, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 102835.5, "10th_percentile": 102835.5, "90th_percentile": 102835.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 17188.1, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 2.1918, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 17188.1, "10th_percentile": 17188.1, "90th_percentile": 17188.1, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 26796.95, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 2.1918, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 26796.95, "10th_percentile": 26796.95, "90th_percentile": 26796.95, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 17532.21, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 2.1918, Rate: 7,999.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 17532.21, "10th_percentile": 17532.21, "90th_percentile": 17532.21, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 17878.51, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 2.1918, Rate: 8,157.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 17878.51, "10th_percentile": 17878.51, "90th_percentile": 17878.51, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 17188.1, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 2.1918, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 17188.1, "10th_percentile": 17188.1, "90th_percentile": 17188.1, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 17188.1, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 2.1918, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 17188.1, "10th_percentile": 17188.1, "90th_percentile": 17188.1, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 26796.95, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 2.1918, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 26796.95, "10th_percentile": 26796.95, "90th_percentile": 26796.95, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_dollar": 15596.48, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 2.19, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $17,569.09; Total: $17,569.09 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17569.09, "10th_percentile": 17569.09, "90th_percentile": 17569.09, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 2.19, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $17,569.09; Total: $17,569.09 Paid at contractual rate, which is the lesser 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": "NWR MEDICARE", "standard_charge_dollar": 15596.48, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 2.19, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $18,677.90; Total: $18,677.90", "median_amount": 18677.9, "10th_percentile": 18677.9, "90th_percentile": 18677.9, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 2.19, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $18,677.90; Total: $18,677.90" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 15596.48, "standard_charge_algorithm": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 2.19, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $17,569.09; Total: $17,569.09 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17569.09, "10th_percentile": 17569.09, "90th_percentile": 17569.09, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.764307766; Using historical claim(s); Scope: All Financial Classes; Cases: 5; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 2.19, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $17,569.09; Total: $17,569.09 Paid at contractual rate, which is 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": "ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC", "code_information": [ { "code": "615", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 9957.18, "maximum": 17107.84, "setting": "inpatient", "gross_charge": 98787.01, "discounted_cash": 69150.91, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_percentage": 34.5, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; Inpatient; 34.5% Billed", "median_amount": 34078.68, "10th_percentile": 34078.68, "90th_percentile": 34078.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_percentage": 36.1, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; Inpatient; 36.1% Billed", "median_amount": 35659.14, "10th_percentile": 35659.14, "90th_percentile": 35659.14, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; Stop Loss; 70% Billed", "median_amount": 69145.14, "10th_percentile": 69145.14, "90th_percentile": 69145.14, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_percentage": 73.0, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All Inpatient Services; 73% Billed", "median_amount": 72108.5, "10th_percentile": 72108.5, "90th_percentile": 72108.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; Inpatient Services; 50% Billed", "median_amount": 49389.39, "10th_percentile": 49389.39, "90th_percentile": 49389.39, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; Inpatient; 30.35% Billed", "median_amount": 29979.36, "10th_percentile": 29979.36, "90th_percentile": 29979.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All IP Services; 100% Billed", "median_amount": 98778.77, "10th_percentile": 98778.77, "90th_percentile": 98778.77, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_percentage": 50.8, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; Inpatient; 50.8% Billed", "median_amount": 50179.62, "10th_percentile": 50179.62, "90th_percentile": 50179.62, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 71.3, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; IP Services. ADP RATE (for patient estimates only); 71.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70429.26, "10th_percentile": 70429.26, "90th_percentile": 70429.26, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; Inpatient; 80% Billed", "median_amount": 79023.02, "10th_percentile": 79023.02, "90th_percentile": 79023.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 74084.08, "10th_percentile": 74084.08, "90th_percentile": 74084.08, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_percentage": 19.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19064.31, "10th_percentile": 19064.31, "90th_percentile": 19064.31, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 17107.84, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.3993, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 17107.84, "10th_percentile": 17107.84, "90th_percentile": 17107.84, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 10973.31, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.3993, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 11083.35, "10th_percentile": 11083.35, "90th_percentile": 11083.35, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 11193.0, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.3993, Rate: 7,999.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 12936.43, "10th_percentile": 12936.43, "90th_percentile": 12936.43, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 11414.09, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.3993, Rate: 8,157.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 13171.47, "10th_percentile": 13171.47, "90th_percentile": 13171.47, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 10973.31, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.3993, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 12688.39, "10th_percentile": 12688.39, "90th_percentile": 12688.39, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 17107.84, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.3993, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 17107.84, "10th_percentile": 17107.84, "90th_percentile": 17107.84, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 10973.31, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.3993, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 11083.35, "10th_percentile": 11083.35, "90th_percentile": 11083.35, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_dollar": 9957.18, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.40, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $12,068.32; Total: $12,068.32", "median_amount": 12068.32, "10th_percentile": 12068.32, "90th_percentile": 12068.32, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.40, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $12,068.32; Total: $12,068.32" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 9957.18, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.40, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $11,360.43; Total: $11,360.43 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11360.43, "10th_percentile": 11360.43, "90th_percentile": 11360.43, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.40, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $11,360.43; Total: $11,360.43 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_dollar": 9957.18, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.40, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $11,360.43; Total: $11,360.43 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11360.43, "10th_percentile": 11360.43, "90th_percentile": 11360.43, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.40, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $11,360.43; Total: $11,360.43 Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 15220.19, "standard_charge_algorithm": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.3993, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 63% of charges. Total pmt for all lines paid so far is less than 63% of claim billed amount.", "median_amount": 15220.19, "10th_percentile": 15220.19, "90th_percentile": 15220.19, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.807344444; Using historical claim(s); Scope: All Financial Classes; Cases: 2; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.3993, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 63% of charges. Total pmt for all lines paid so far is less than 63% of claim billed amount." } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "560", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 8830.88, "maximum": 22175.83, "setting": "inpatient", "gross_charge": 74730.24, "discounted_cash": 52311.17, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 14498.54, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 12,875.00, 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": 74730.25, "10th_percentile": 74730.25, "90th_percentile": 74730.25, "count": "83", "methodology": "fee schedule" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 10719.35, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 9,519.00, 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": 74730.25, "10th_percentile": 74730.25, "90th_percentile": 74730.25, "count": "83", "methodology": "fee schedule" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 22175.83, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; IP Rehab; FSC: HB MRH & NWR CMG IP REHAB RATES, and; Pricing Extension - NM HB XR PRC - NWR IP REHAB PPS MEDICARE & 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": 22887.68, "10th_percentile": 22887.68, "90th_percentile": 22887.68, "count": "83", "methodology": "case rate" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_dollar": 22175.83, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; IP Rehab; FSC: HB MRH & NWR CMG IP REHAB RATES, and; Pricing Extension - NM HB XR PRC - NWR IP REHAB PPS MEDICARE & 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": 22887.68, "10th_percentile": 22887.68, "90th_percentile": 22887.68, "count": "83", "methodology": "case rate" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_dollar": 22175.83, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; IP Rehab; FSC: HB MRH & NWR CMG IP REHAB RATES, and; Pricing Extension - NM HB XR PRC - NWR IP REHAB PPS MEDICARE", "median_amount": 26221.92, "10th_percentile": 26221.92, "90th_percentile": 26221.92, "count": "83", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 13767.7, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 77369.0, "10th_percentile": 77369.0, "90th_percentile": 77369.0, "count": "83", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 8830.88, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 8830.88, "10th_percentile": 8830.88, "90th_percentile": 8830.88, "count": "83", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 9007.67, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 7,999.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 9343.35, "10th_percentile": 9343.35, "90th_percentile": 9343.35, "count": "83", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 9185.6, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 8,157.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 9512.02, "10th_percentile": 9512.02, "90th_percentile": 9512.02, "count": "83", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 8830.88, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 9165.17, "10th_percentile": 9165.17, "90th_percentile": 9165.17, "count": "83", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 13767.7, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 77369.0, "10th_percentile": 77369.0, "90th_percentile": 77369.0, "count": "83", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 8830.88, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 8830.88, "10th_percentile": 8830.88, "90th_percentile": 8830.88, "count": "83", "methodology": "case rate" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_percentage": 34.5, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; Inpatient; 34.5% Billed", "median_amount": 25781.94, "10th_percentile": 25781.94, "90th_percentile": 25781.94, "count": "83", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_percentage": 36.1, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; Inpatient; 36.1% Billed", "median_amount": 26977.62, "10th_percentile": 26977.62, "90th_percentile": 26977.62, "count": "83", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_percentage": 19.3, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and therapy services can be included in reimbursement.", "median_amount": 14422.96, "10th_percentile": 14422.96, "90th_percentile": 14422.96, "count": "83", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; Stop Loss; 70% Billed", "median_amount": 52311.18, "10th_percentile": 52311.18, "90th_percentile": 52311.18, "count": "83", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_percentage": 73.0, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; All Inpatient Services; 73% Billed", "median_amount": 54553.08, "10th_percentile": 54553.08, "90th_percentile": 54553.08, "count": "83", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; Inpatient Services; 50% Billed", "median_amount": 37365.13, "10th_percentile": 37365.13, "90th_percentile": 37365.13, "count": "83", "methodology": "percent of total billed charges" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; Inpatient; 30.35% Billed", "median_amount": 22680.63, "10th_percentile": 22680.63, "90th_percentile": 22680.63, "count": "83", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; All IP Services; 100% Billed", "median_amount": 74730.25, "10th_percentile": 74730.25, "90th_percentile": 74730.25, "count": "83", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_percentage": 50.8, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; Inpatient; 50.8% Billed", "median_amount": 37962.97, "10th_percentile": 37962.97, "90th_percentile": 37962.97, "count": "83", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, and therapy services can be included in reimbursement.", "median_amount": 56047.69, "10th_percentile": 56047.69, "90th_percentile": 56047.69, "count": "83", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 71.3, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; IP Services. ADP RATE (for patient estimates only); 71.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53282.67, "10th_percentile": 53282.67, "90th_percentile": 53282.67, "count": "83", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; Inpatient; 80% Billed", "median_amount": 59784.2, "10th_percentile": 59784.2, "90th_percentile": 59784.2, "count": "83", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 12248.59, "standard_charge_algorithm": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 63% of charges. Total pmt for all lines paid so far is less than 63% of claim billed amount.", "median_amount": 12248.59, "10th_percentile": 12248.59, "90th_percentile": 12248.59, "count": "83", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.825521106; Using historical claim(s); Scope: All Financial Classes; Cases: 83; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 63% of charges. Total pmt for all lines paid so far is less than 63% of claim billed amount." } ] } ] }, { "description": "AGENT BULKING 1ML DURASPHERE EXP SUBMUCOSAL INJ SYR PREFLL", "code_information": [ { "code": "SUP-313296", "type": "CDM" }, { "code": "L8606", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 163.28, "maximum": 846.0, "setting": "outpatient", "gross_charge": 846.0, "discounted_cash": 592.2, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 404.39, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 404.39, "10th_percentile": 404.39, "90th_percentile": 404.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 404.39, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 404.39, "10th_percentile": 404.39, "90th_percentile": 404.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 404.39, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 404.39, "10th_percentile": 404.39, "90th_percentile": 404.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 301.85, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 301.85, "10th_percentile": 301.85, "90th_percentile": 301.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 301.85, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 301.85, "10th_percentile": 301.85, "90th_percentile": 301.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 247.03, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.03, "10th_percentile": 247.03, "90th_percentile": 247.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 247.03, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.03, "10th_percentile": 247.03, "90th_percentile": 247.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 286.79, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 286.79, "10th_percentile": 286.79, "90th_percentile": 286.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 286.79, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 286.79, "10th_percentile": 286.79, "90th_percentile": 286.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 450.07, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 450.07, "10th_percentile": 450.07, "90th_percentile": 450.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 846.0, "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 $846.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 846.0, "10th_percentile": 846.0, "90th_percentile": 846.0, "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 $846.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 261.41, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 261.41, "10th_percentile": 261.41, "90th_percentile": 261.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 300.33, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 300.33, "10th_percentile": 300.33, "90th_percentile": 300.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 166.66, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 166.66, "10th_percentile": 166.66, "90th_percentile": 166.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 163.28, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 163.28, "10th_percentile": 163.28, "90th_percentile": 163.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 291.02, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 291.02, "10th_percentile": 291.02, "90th_percentile": 291.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 634.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 634.5, "10th_percentile": 634.5, "90th_percentile": 634.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 592.2, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 592.2, "10th_percentile": 592.2, "90th_percentile": 592.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 846.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 846.0, "10th_percentile": 846.0, "90th_percentile": 846.0, "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": "NWR HFN PPO", "standard_charge_dollar": 617.58, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 617.58, "10th_percentile": 617.58, "90th_percentile": 617.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 256.76, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 256.76, "10th_percentile": 256.76, "90th_percentile": 256.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 676.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 676.8, "10th_percentile": 676.8, "90th_percentile": 676.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 423.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 423.0, "10th_percentile": 423.0, "90th_percentile": 423.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 846.0, "10th_percentile": 846.0, "90th_percentile": 846.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 846.0, "10th_percentile": 846.0, "90th_percentile": 846.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $846.00 @ 12.5% = $105.75 due to $0.00 Claim Price", "median_amount": 105.75, "10th_percentile": 105.75, "90th_percentile": 105.75, "count": "0", "methodology": "other", "additional_payer_notes": "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: $846.00 @ 12.5% = $105.75 due to $0.00 Claim Price" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 401.0, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 401.0, "10th_percentile": 401.0, "90th_percentile": 401.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 445.84, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 445.84, "10th_percentile": 445.84, "90th_percentile": 445.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 543.39, "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": 543.39, "10th_percentile": 543.39, "90th_percentile": 543.39, "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": "NWR PHCS PPO", "standard_charge_dollar": 532.98, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $532.98 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 532.98, "10th_percentile": 532.98, "90th_percentile": 532.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $532.98 so that total pmt for all claim lines does not exceed 63% of claim billed amount." } ] } ] }, { "description": "AICD GENERATOR PROCEDURES", "code_information": [ { "code": "245", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 32465.28, "maximum": 55779.9, "setting": "inpatient", "gross_charge": 253522.73, "discounted_cash": 177465.92, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_percentage": 37.8, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Stop Loss; 37.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 95831.6, "10th_percentile": 95831.6, "90th_percentile": 95831.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_percentage": 53.1, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Stop Loss; 53.1% 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": 134620.56, "10th_percentile": 134620.56, "90th_percentile": 134620.56, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_percentage": 19.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 48929.92, "10th_percentile": 48929.92, "90th_percentile": 48929.92, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_percentage": 34.5, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient; 34.5% Billed", "median_amount": 87465.35, "10th_percentile": 87465.35, "90th_percentile": 87465.35, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_percentage": 36.1, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient; 36.1% Billed", "median_amount": 91521.71, "10th_percentile": 91521.71, "90th_percentile": 91521.71, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Stop Loss; 70% Billed", "median_amount": 177465.92, "10th_percentile": 177465.92, "90th_percentile": 177465.92, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_percentage": 73.0, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All Inpatient Services; 73% Billed", "median_amount": 185071.6, "10th_percentile": 185071.6, "90th_percentile": 185071.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 71.3, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; IP Services. ADP RATE (for patient estimates only); 71.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 180761.7, "10th_percentile": 180761.7, "90th_percentile": 180761.7, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient; 30.35% Billed", "median_amount": 76944.15, "10th_percentile": 76944.15, "90th_percentile": 76944.15, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_percentage": 50.8, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient; 50.8% Billed", "median_amount": 128789.55, "10th_percentile": 128789.55, "90th_percentile": 128789.55, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient Services; 50% Billed", "median_amount": 126761.37, "10th_percentile": 126761.37, "90th_percentile": 126761.37, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient; 80% Billed", "median_amount": 202818.19, "10th_percentile": 202818.19, "90th_percentile": 202818.19, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; 100% Billed", "median_amount": 253522.73, "10th_percentile": 253522.73, "90th_percentile": 253522.73, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 190142.06, "10th_percentile": 190142.06, "90th_percentile": 190142.06, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_percentage": 29.7, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Stop Loss; 29.7% Billed", "median_amount": 75296.25, "10th_percentile": 75296.25, "90th_percentile": 75296.25, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_percentage": 20.3, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Stop Loss; 20.3% Billed", "median_amount": 51465.12, "10th_percentile": 51465.12, "90th_percentile": 51465.12, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 35778.34, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 4.5624, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 35778.34, "10th_percentile": 35778.34, "90th_percentile": 35778.34, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 55779.9, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 4.5624, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 55779.9, "10th_percentile": 55779.9, "90th_percentile": 55779.9, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 36494.64, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 4.5624, Rate: 7,999.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 36494.64, "10th_percentile": 36494.64, "90th_percentile": 36494.64, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 37215.5, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 4.5624, Rate: 8,157.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 37215.5, "10th_percentile": 37215.5, "90th_percentile": 37215.5, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 35778.34, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 4.5624, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 35778.34, "10th_percentile": 35778.34, "90th_percentile": 35778.34, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 35778.34, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 4.5624, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 35778.34, "10th_percentile": 35778.34, "90th_percentile": 35778.34, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 55779.9, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 4.5624, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 55779.9, "10th_percentile": 55779.9, "90th_percentile": 55779.9, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_percentage": 64.0, "standard_charge_algorithm": "May include reimbursement for certain add-on services.", "median_amount": 159719.33, "10th_percentile": 159719.33, "90th_percentile": 159719.33, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; IP Stop Loss 1 & 2; 64% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid $159,719.33 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_dollar": 32465.28, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 4.56, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $36,141.01; Total: $36,141.01 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36141.01, "10th_percentile": 36141.01, "90th_percentile": 36141.01, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 4.56, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $36,141.01; Total: $36,141.01 Paid at contractual rate, which is the lesser 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": "NWR MEDICARE", "standard_charge_dollar": 32465.28, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 4.56, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $36,141.01; Total: $36,141.01", "median_amount": 36141.01, "10th_percentile": 36141.01, "90th_percentile": 36141.01, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 4.56, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $36,141.01; Total: $36,141.01" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 32465.28, "standard_charge_algorithm": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 4.56, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $36,141.01; Total: $36,141.01 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36141.01, "10th_percentile": 36141.01, "90th_percentile": 36141.01, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.810968570; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 4.56, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $36,141.01; Total: $36,141.01 Paid at contractual rate, which is 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": "AICD LEAD STYLETS MODEL 6972 0.014INX64CM", "code_information": [ { "code": "SUP-312691", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 41.42, "maximum": 214.63, "setting": "outpatient", "gross_charge": 214.63, "discounted_cash": 150.24, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 214.63, "10th_percentile": 214.63, "90th_percentile": 214.63, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 214.63, "10th_percentile": 214.63, "90th_percentile": 214.63, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 214.63, "10th_percentile": 214.63, "90th_percentile": 214.63, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 60.29, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.29, "10th_percentile": 60.29, "90th_percentile": 60.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 60.29, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.29, "10th_percentile": 60.29, "90th_percentile": 60.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 76.58, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.58, "10th_percentile": 76.58, "90th_percentile": 76.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 76.58, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.58, "10th_percentile": 76.58, "90th_percentile": 76.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 83.6, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 83.6, "10th_percentile": 83.6, "90th_percentile": 83.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 83.6, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 83.6, "10th_percentile": 83.6, "90th_percentile": 83.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 76.19, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 76.19, "10th_percentile": 76.19, "90th_percentile": 76.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 112.68, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 112.68, "10th_percentile": 112.68, "90th_percentile": 112.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 73.83, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 73.83, "10th_percentile": 73.83, "90th_percentile": 73.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 104.52, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 104.52, "10th_percentile": 104.52, "90th_percentile": 104.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 41.42, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 41.42, "10th_percentile": 41.42, "90th_percentile": 41.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 137.86, "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": 137.86, "10th_percentile": 137.86, "90th_percentile": 137.86, "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": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 160.97, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 160.97, "10th_percentile": 160.97, "90th_percentile": 160.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 63.29, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.29, "10th_percentile": 63.29, "90th_percentile": 63.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 65.14, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% 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; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 101.73, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 101.73, "10th_percentile": 101.73, "90th_percentile": 101.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 156.68, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 156.68, "10th_percentile": 156.68, "90th_percentile": 156.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 114.18, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 114.18, "10th_percentile": 114.18, "90th_percentile": 114.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 135.22, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $135.22 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 135.22, "10th_percentile": 135.22, "90th_percentile": 135.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $135.22 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 214.63, "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 $214.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 214.63, "10th_percentile": 214.63, "90th_percentile": 214.63, "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 $214.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 214.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 214.63, "10th_percentile": 214.63, "90th_percentile": 214.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 42.28, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.28, "10th_percentile": 42.28, "90th_percentile": 42.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 113.11, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 113.11, "10th_percentile": 113.11, "90th_percentile": 113.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 107.32, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 107.32, "10th_percentile": 107.32, "90th_percentile": 107.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 171.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 171.7, "10th_percentile": 171.7, "90th_percentile": 171.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 66.32, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 66.32, "10th_percentile": 66.32, "90th_percentile": 66.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 150.24, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 150.24, "10th_percentile": 150.24, "90th_percentile": 150.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" } ] } ] }, { "description": "AIRWAY GUEDEL DISPO 60MM", "code_information": [ { "code": "SUP-337765", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 0.24, "maximum": 1.23, "setting": "outpatient", "gross_charge": 1.23, "discounted_cash": 0.86, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1.23, "10th_percentile": 1.23, "90th_percentile": 1.23, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1.23, "10th_percentile": 1.23, "90th_percentile": 1.23, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1.23, "10th_percentile": 1.23, "90th_percentile": 1.23, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.35, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.35, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.44, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 0.44, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.48, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.48, "10th_percentile": 0.48, "90th_percentile": 0.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.48, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.48, "10th_percentile": 0.48, "90th_percentile": 0.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.44, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.44, "10th_percentile": 0.44, "90th_percentile": 0.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 0.65, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.65, "10th_percentile": 0.65, "90th_percentile": 0.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.42, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.42, "10th_percentile": 0.42, "90th_percentile": 0.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 0.6, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.6, "10th_percentile": 0.6, "90th_percentile": 0.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.24, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.24, "10th_percentile": 0.24, "90th_percentile": 0.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 0.79, "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": 0.79, "10th_percentile": 0.79, "90th_percentile": 0.79, "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": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 0.92, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 0.92, "10th_percentile": 0.92, "90th_percentile": 0.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.36, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.37, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 0.58, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.58, "10th_percentile": 0.58, "90th_percentile": 0.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 0.9, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 0.9, "10th_percentile": 0.9, "90th_percentile": 0.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 0.65, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 0.65, "10th_percentile": 0.65, "90th_percentile": 0.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 0.77, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $0.77 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 0.77, "10th_percentile": 0.77, "90th_percentile": 0.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $0.77 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1.23, "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 $1.23 so that total pmt for all claim lines does not exceed 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": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1.23 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1.23, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.23, "10th_percentile": 1.23, "90th_percentile": 1.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.24, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.24, "10th_percentile": 0.24, "90th_percentile": 0.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 0.65, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.65, "10th_percentile": 0.65, "90th_percentile": 0.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 0.62, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 0.98, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 0.98, "10th_percentile": 0.98, "90th_percentile": 0.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.38, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 0.86, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 0.86, "10th_percentile": 0.86, "90th_percentile": 0.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" } ] } ] }, { "description": "AIRWY MSK FLEX LMA SZ 2.0 DISP", "code_information": [ { "code": "SUP-313720", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 16.15, "maximum": 83.7, "setting": "outpatient", "gross_charge": 83.7, "discounted_cash": 58.59, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 83.7, "10th_percentile": 83.7, "90th_percentile": 83.7, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 83.7, "10th_percentile": 83.7, "90th_percentile": 83.7, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 83.7, "10th_percentile": 83.7, "90th_percentile": 83.7, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 32.6, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.6, "10th_percentile": 32.6, "90th_percentile": 32.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 32.6, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.6, "10th_percentile": 32.6, "90th_percentile": 32.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 29.86, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.86, "10th_percentile": 29.86, "90th_percentile": 29.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 29.86, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.86, "10th_percentile": 29.86, "90th_percentile": 29.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 23.51, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.51, "10th_percentile": 23.51, "90th_percentile": 23.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 23.51, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.51, "10th_percentile": 23.51, "90th_percentile": 23.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 40.76, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40.76, "10th_percentile": 40.76, "90th_percentile": 40.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 16.15, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 16.15, "10th_percentile": 16.15, "90th_percentile": 16.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 43.94, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.94, "10th_percentile": 43.94, "90th_percentile": 43.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 29.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 29.71, "10th_percentile": 29.71, "90th_percentile": 29.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 28.79, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 28.79, "10th_percentile": 28.79, "90th_percentile": 28.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 44.53, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 44.53, "10th_percentile": 44.53, "90th_percentile": 44.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 39.67, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 39.67, "10th_percentile": 39.67, "90th_percentile": 39.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 25.4, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 25.4, "10th_percentile": 25.4, "90th_percentile": 25.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 53.76, "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": 53.76, "10th_percentile": 53.76, "90th_percentile": 53.76, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 16.49, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.49, "10th_percentile": 16.49, "90th_percentile": 16.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 66.96, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 66.96, "10th_percentile": 66.96, "90th_percentile": 66.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 44.11, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 44.11, "10th_percentile": 44.11, "90th_percentile": 44.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 83.7, "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 $83.70 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 83.7, "10th_percentile": 83.7, "90th_percentile": 83.7, "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 $83.70 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 52.73, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $52.73 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 52.73, "10th_percentile": 52.73, "90th_percentile": 52.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $52.73 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 24.68, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.68, "10th_percentile": 24.68, "90th_percentile": 24.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 62.78, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 62.78, "10th_percentile": 62.78, "90th_percentile": 62.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 58.59, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 58.59, "10th_percentile": 58.59, "90th_percentile": 58.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 61.1, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 61.1, "10th_percentile": 61.1, "90th_percentile": 61.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 25.86, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.86, "10th_percentile": 25.86, "90th_percentile": 25.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 83.7, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 83.7, "10th_percentile": 83.7, "90th_percentile": 83.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 41.85, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 41.85, "10th_percentile": 41.85, "90th_percentile": 41.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" } ] } ] }, { "description": "ALBUMIN, HUMAN 25 % IV SOLP", "drug_information": { "unit": 50.0, "type": "ML" }, "code_information": [ { "code": "RX-8981", "type": "CDM" }, { "code": "P9047", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "68516-5216-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 40.82, "maximum": 211.5, "setting": "outpatient", "gross_charge": 211.5, "discounted_cash": 148.05, "payers_information": [ { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 64.19, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 64.19, "10th_percentile": 64.19, "90th_percentile": 64.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 211.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 211.5, "10th_percentile": 211.5, "90th_percentile": 211.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 133.25, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $133.25 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 133.25, "10th_percentile": 133.25, "90th_percentile": 133.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $133.25 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 211.5, "10th_percentile": 211.5, "90th_percentile": 211.5, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 211.5, "10th_percentile": 211.5, "90th_percentile": 211.5, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 211.5, "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 $211.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 211.5, "10th_percentile": 211.5, "90th_percentile": 211.5, "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 $211.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 40.82, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 40.82, "10th_percentile": 40.82, "90th_percentile": 40.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 72.76, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 72.76, "10th_percentile": 72.76, "90th_percentile": 72.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 112.52, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 112.52, "10th_percentile": 112.52, "90th_percentile": 112.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 169.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 169.2, "10th_percentile": 169.2, "90th_percentile": 169.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 75.08, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 75.08, "10th_percentile": 75.08, "90th_percentile": 75.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 158.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 158.63, "10th_percentile": 158.63, "90th_percentile": 158.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 105.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 105.75, "10th_percentile": 105.75, "90th_percentile": 105.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 154.4, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 154.4, "10th_percentile": 154.4, "90th_percentile": 154.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 148.05, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 148.05, "10th_percentile": 148.05, "90th_percentile": 148.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 111.04, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 111.04, "10th_percentile": 111.04, "90th_percentile": 111.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 71.7, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.7, "10th_percentile": 71.7, "90th_percentile": 71.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 71.7, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.7, "10th_percentile": 71.7, "90th_percentile": 71.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 75.46, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 75.46, "10th_percentile": 75.46, "90th_percentile": 75.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 75.46, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 75.46, "10th_percentile": 75.46, "90th_percentile": 75.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 101.1, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.1, "10th_percentile": 101.1, "90th_percentile": 101.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 101.1, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.1, "10th_percentile": 101.1, "90th_percentile": 101.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 101.1, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.1, "10th_percentile": 101.1, "90th_percentile": 101.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $211.50 @ 12.5% = $26.44 due to $0.00 Claim Price", "median_amount": 33.17, "10th_percentile": 33.17, "90th_percentile": 33.17, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "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: $211.50 @ 12.5% = $26.44 due to $0.00 Claim Price" } ] } ] }, { "description": "ALBUMIN, HUMAN 5 % IV SOLP", "drug_information": { "unit": 500.0, "type": "ML" }, "code_information": [ { "code": "RX-8982", "type": "CDM" }, { "code": "P9045", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "68982-0623-03", "type": "NDC" } ], "standard_charges": [ { "minimum": 100.84, "maximum": 522.5, "setting": "outpatient", "gross_charge": 522.5, "discounted_cash": 365.75, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $522.50 @ 12.5% = $65.31 due to $0.00 Claim Price", "median_amount": 65.31, "10th_percentile": 65.31, "90th_percentile": 65.31, "count": "0", "methodology": "other", "additional_payer_notes": "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: $522.50 @ 12.5% = $65.31 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 522.5, "10th_percentile": 522.5, "90th_percentile": 522.5, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 522.5, "10th_percentile": 522.5, "90th_percentile": 522.5, "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 249.76, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 249.76, "10th_percentile": 249.76, "90th_percentile": 249.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 249.76, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 249.76, "10th_percentile": 249.76, "90th_percentile": 249.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 249.76, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 249.76, "10th_percentile": 249.76, "90th_percentile": 249.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 186.43, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 186.43, "10th_percentile": 186.43, "90th_percentile": 186.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 186.43, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 186.43, "10th_percentile": 186.43, "90th_percentile": 186.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 177.13, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 177.13, "10th_percentile": 177.13, "90th_percentile": 177.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 177.13, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 177.13, "10th_percentile": 177.13, "90th_percentile": 177.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 185.49, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 185.49, "10th_percentile": 185.49, "90th_percentile": 185.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 179.74, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 179.74, "10th_percentile": 179.74, "90th_percentile": 179.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 391.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 391.88, "10th_percentile": 391.88, "90th_percentile": 391.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 158.58, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 158.58, "10th_percentile": 158.58, "90th_percentile": 158.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 261.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 261.25, "10th_percentile": 261.25, "90th_percentile": 261.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 274.31, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 274.31, "10th_percentile": 274.31, "90th_percentile": 274.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 381.43, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 381.43, "10th_percentile": 381.43, "90th_percentile": 381.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 418.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 418.0, "10th_percentile": 418.0, "90th_percentile": 418.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 522.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 522.5, "10th_percentile": 522.5, "90th_percentile": 522.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 100.84, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 100.84, "10th_percentile": 100.84, "90th_percentile": 100.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 365.75, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 365.75, "10th_percentile": 365.75, "90th_percentile": 365.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 277.97, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 277.97, "10th_percentile": 277.97, "90th_percentile": 277.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 522.5, "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 $522.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 522.5, "10th_percentile": 522.5, "90th_percentile": 522.5, "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 $522.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 329.18, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $329.18 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 329.18, "10th_percentile": 329.18, "90th_percentile": 329.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $329.18 so that total pmt for all claim lines does not exceed 63% of claim billed amount." } ] } ] }, { "description": "ALBUTEROL SULFATE 1.25 MG/3 ML INH NEBU", "drug_information": { "unit": 3.0, "type": "ML" }, "code_information": [ { "code": "RX-31578", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "76204-0011-05", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.68, "maximum": 3.5, "setting": "outpatient", "gross_charge": 3.5, "discounted_cash": 2.45, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "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": "NWR 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": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.25, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.25, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1.36, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1.36, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.98, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.98, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.68, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% 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 Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1.24, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1.24, "10th_percentile": 1.24, "90th_percentile": 1.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1.84, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.84, "10th_percentile": 1.84, "90th_percentile": 1.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 1.2, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 1.7, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 2.56, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 2.56, "10th_percentile": 2.56, "90th_percentile": 2.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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": "HEALTHLINK [125]", "plan_name": "NWR 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": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.86, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.86, "10th_percentile": 1.86, "90th_percentile": 1.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.03, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.69, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 1.08, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2.45, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 2.25, "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": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "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": "NWR UHC CORE", "standard_charge_dollar": 1.66, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1.66, "10th_percentile": 1.66, "90th_percentile": 1.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.84, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.84, "10th_percentile": 1.84, "90th_percentile": 1.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR PHCS PPO", "standard_charge_dollar": 2.21, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2.21 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 2.21, "10th_percentile": 2.21, "90th_percentile": 2.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2.21 so that total pmt for all claim lines does not exceed 63% of claim billed amount." } ] } ] }, { "description": "ALBUTEROL SULFATE 2.5 MG /3 ML (0.083 %) INH NEBU", "drug_information": { "unit": 1.5, "type": "ML" }, "code_information": [ { "code": "RX-250", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0250", "type": "RC" }, { "code": "76204-0200-25", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.14, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": 0.43, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.47, "10th_percentile": 0.3, "90th_percentile": 0.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.72, "10th_percentile": 0.46, "90th_percentile": 0.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.49, "10th_percentile": 0.31, "90th_percentile": 0.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.27, "10th_percentile": 0.17, "90th_percentile": 0.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "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": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": 0.31, "90th_percentile": 0.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": 0.29, "90th_percentile": 0.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1.6, "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": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $2.00 @ 12.5% = $0.25 due to $0.00 Claim Price", "median_amount": 0.17, "10th_percentile": 0.11, "90th_percentile": 0.23, "count": "0", "methodology": "other", "additional_payer_notes": "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: $2.00 @ 12.5% = $0.25 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": 0.42, "90th_percentile": 0.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": 0.42, "90th_percentile": 0.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": 0.42, "90th_percentile": 0.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": 0.31, "90th_percentile": 0.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": 1.38, "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 $2.00 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": "NWR BCBS PPO", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": 0.29, "90th_percentile": 0.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 0.73, "10th_percentile": 0.47, "90th_percentile": 0.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.0, "10th_percentile": 0.64, "90th_percentile": 1.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.42, "10th_percentile": 0.27, "90th_percentile": 0.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "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": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 0.86, "10th_percentile": 0.55, "90th_percentile": 1.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": 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": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.66, "10th_percentile": 0.42, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.73, "10th_percentile": 0.47, "90th_percentile": 0.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": 0.19, "maximum": 2.0, "setting": "outpatient", "gross_charge": 1.0, "discounted_cash": 0.7, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 0.49, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.73, "10th_percentile": 0.54, "90th_percentile": 0.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.34, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.52, "10th_percentile": 0.38, "90th_percentile": 0.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 0.53, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.79, "10th_percentile": 0.58, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.36, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.53, "10th_percentile": 0.4, "90th_percentile": 0.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.19, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.29, "10th_percentile": 0.21, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.36, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": 0.4, "90th_percentile": 0.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.34, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": 0.37, "90th_percentile": 0.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 0.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.2, "10th_percentile": 0.88, "90th_percentile": 1.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.48, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.72, "10th_percentile": 0.53, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.48, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.72, "10th_percentile": 0.53, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.48, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.72, "10th_percentile": 0.53, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.36, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": 0.4, "90th_percentile": 0.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1.0, "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 $1.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1.5, "10th_percentile": 1.1, "90th_percentile": 1.9, "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 $1.00 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": "NWR BCBS PPO", "standard_charge_dollar": 0.34, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": 0.37, "90th_percentile": 0.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 0.53, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 0.8, "10th_percentile": 0.58, "90th_percentile": 1.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1.13, "10th_percentile": 0.83, "90th_percentile": 1.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 0.7, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1.05, "10th_percentile": 0.77, "90th_percentile": 1.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 0.73, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.09, "10th_percentile": 0.8, "90th_percentile": 1.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 0.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 0.75, "10th_percentile": 0.55, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.3, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.45, "10th_percentile": 0.33, "90th_percentile": 0.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.5, "10th_percentile": 1.1, "90th_percentile": 1.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 0.63, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $0.63 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 0.95, "10th_percentile": 0.69, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $0.63 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 0.64, "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": 0.96, "10th_percentile": 0.7, "90th_percentile": 1.22, "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": "NWR UHC CORE", "standard_charge_dollar": 0.47, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.71, "10th_percentile": 0.52, "90th_percentile": 0.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 0.53, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.79, "10th_percentile": 0.58, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1.5, "10th_percentile": 1.1, "90th_percentile": 1.9, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1.5, "10th_percentile": 1.1, "90th_percentile": 1.9, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1.00 @ 12.5% = $0.13 due to $0.00 Claim Price", "median_amount": 0.19, "10th_percentile": 0.14, "90th_percentile": 0.24, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1.00 @ 12.5% = $0.13 due to $0.00 Claim Price" } ] } ] }, { "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": 0.63, "maximum": 3.25, "setting": "outpatient", "gross_charge": 3.25, "discounted_cash": 2.27, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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": "NWR AETNA", "standard_charge_dollar": 1.58, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.58, "10th_percentile": 1.58, "90th_percentile": 1.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 1.12, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1.12, "10th_percentile": 1.12, "90th_percentile": 1.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1.71, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1.15, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1.15, "10th_percentile": 1.15, "90th_percentile": 1.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.63, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.63, "10th_percentile": 0.63, "90th_percentile": 0.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.16, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.16, "10th_percentile": 1.16, "90th_percentile": 1.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1.27, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.96, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.91, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.91, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.16, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.16, "10th_percentile": 1.16, "90th_percentile": 1.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1.27, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.73, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.73, "10th_percentile": 1.73, "90th_percentile": 1.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.64, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.64, "10th_percentile": 0.64, "90th_percentile": 0.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 1.0, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2.28, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 2.37, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% 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; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.99, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.99, "10th_percentile": 0.99, "90th_percentile": 0.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 2.05, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2.05 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2.05 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "NWR UHC CORE", "standard_charge_dollar": 1.54, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1.54, "10th_percentile": 1.54, "90th_percentile": 1.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.71, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "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": "GLOBAL EXCEL [1712]", "plan_name": "NWR 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": "ALBUTEROL SULFATE 90 MCG/ACTUATION INH HFAA", "drug_information": { "unit": 8.5, "type": "GR" }, "code_information": [ { "code": "RX-17837", "type": "CDM" }, { "code": "CHRG1841", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "45802-0088-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.41, "maximum": 162.75, "setting": "outpatient", "gross_charge": 162.75, "discounted_cash": 113.92, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 162.75, "10th_percentile": 162.75, "90th_percentile": 162.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 162.75, "10th_percentile": 162.75, "90th_percentile": 162.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 162.75, "10th_percentile": 162.75, "90th_percentile": 162.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 79.26, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.26, "10th_percentile": 79.26, "90th_percentile": 79.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 55.99, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 55.99, "10th_percentile": 55.99, "90th_percentile": 55.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 85.44, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.44, "10th_percentile": 85.44, "90th_percentile": 85.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 57.78, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 57.78, "10th_percentile": 57.78, "90th_percentile": 57.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 31.41, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 31.41, "10th_percentile": 31.41, "90th_percentile": 31.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 58.07, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 58.07, "10th_percentile": 58.07, "90th_percentile": 58.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 63.39, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.39, "10th_percentile": 63.39, "90th_percentile": 63.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 130.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 130.2, "10th_percentile": 130.2, "90th_percentile": 130.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 47.99, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.99, "10th_percentile": 47.99, "90th_percentile": 47.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 45.72, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.72, "10th_percentile": 45.72, "90th_percentile": 45.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 45.72, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.72, "10th_percentile": 45.72, "90th_percentile": 45.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 58.07, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 58.07, "10th_percentile": 58.07, "90th_percentile": 58.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 162.75, "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 $162.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 162.75, "10th_percentile": 162.75, "90th_percentile": 162.75, "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 $162.75 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": "NWR BCBS PPO", "standard_charge_dollar": 63.39, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.39, "10th_percentile": 63.39, "90th_percentile": 63.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 86.58, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 86.58, "10th_percentile": 86.58, "90th_percentile": 86.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 32.06, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.06, "10th_percentile": 32.06, "90th_percentile": 32.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 122.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 122.06, "10th_percentile": 122.06, "90th_percentile": 122.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 50.29, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.29, "10th_percentile": 50.29, "90th_percentile": 50.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 113.93, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 113.93, "10th_percentile": 113.93, "90th_percentile": 113.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 118.81, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 118.81, "10th_percentile": 118.81, "90th_percentile": 118.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 81.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 81.38, "10th_percentile": 81.38, "90th_percentile": 81.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 49.39, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 49.39, "10th_percentile": 49.39, "90th_percentile": 49.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 162.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 162.75, "10th_percentile": 162.75, "90th_percentile": 162.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 102.53, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $102.53 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 102.53, "10th_percentile": 102.53, "90th_percentile": 102.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $102.53 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 104.53, "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": 104.53, "10th_percentile": 104.53, "90th_percentile": 104.53, "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": "NWR UHC CORE", "standard_charge_dollar": 77.14, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 77.14, "10th_percentile": 77.14, "90th_percentile": 77.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 85.77, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.77, "10th_percentile": 85.77, "90th_percentile": 85.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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 90 MCG/ACTUATION INH HFAA", "drug_information": { "unit": 6.7, "type": "GR" }, "code_information": [ { "code": "RX-17837", "type": "CDM" }, { "code": "CHRG1841", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "69097-0142-60", "type": "NDC" } ], "standard_charges": [ { "minimum": 31.41, "maximum": 162.75, "setting": "outpatient", "gross_charge": 162.75, "discounted_cash": 113.92, "payers_information": [ { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 81.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 81.38, "10th_percentile": 81.38, "90th_percentile": 81.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 49.39, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 49.39, "10th_percentile": 49.39, "90th_percentile": 49.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 162.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 162.75, "10th_percentile": 162.75, "90th_percentile": 162.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 102.53, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $102.53 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 102.53, "10th_percentile": 102.53, "90th_percentile": 102.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $102.53 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 104.53, "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": 104.53, "10th_percentile": 104.53, "90th_percentile": 104.53, "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": "NWR UHC CORE", "standard_charge_dollar": 77.14, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 77.14, "10th_percentile": 77.14, "90th_percentile": 77.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 85.77, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.77, "10th_percentile": 85.77, "90th_percentile": 85.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 79.26, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.26, "10th_percentile": 79.26, "90th_percentile": 79.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 55.99, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 55.99, "10th_percentile": 55.99, "90th_percentile": 55.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 85.44, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 85.44, "10th_percentile": 85.44, "90th_percentile": 85.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 57.78, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 57.78, "10th_percentile": 57.78, "90th_percentile": 57.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 31.41, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 31.41, "10th_percentile": 31.41, "90th_percentile": 31.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 58.07, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 58.07, "10th_percentile": 58.07, "90th_percentile": 58.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 63.39, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.39, "10th_percentile": 63.39, "90th_percentile": 63.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 130.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 130.2, "10th_percentile": 130.2, "90th_percentile": 130.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 47.99, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.99, "10th_percentile": 47.99, "90th_percentile": 47.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 45.72, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.72, "10th_percentile": 45.72, "90th_percentile": 45.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 45.72, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.72, "10th_percentile": 45.72, "90th_percentile": 45.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 58.07, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 58.07, "10th_percentile": 58.07, "90th_percentile": 58.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 162.75, "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 $162.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 162.75, "10th_percentile": 162.75, "90th_percentile": 162.75, "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 $162.75 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": "NWR BCBS PPO", "standard_charge_dollar": 63.39, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.39, "10th_percentile": 63.39, "90th_percentile": 63.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 86.58, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 86.58, "10th_percentile": 86.58, "90th_percentile": 86.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 32.06, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.06, "10th_percentile": 32.06, "90th_percentile": 32.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 122.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 122.06, "10th_percentile": 122.06, "90th_percentile": 122.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 50.29, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.29, "10th_percentile": 50.29, "90th_percentile": 50.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 113.93, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 113.93, "10th_percentile": 113.93, "90th_percentile": 113.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 118.81, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 118.81, "10th_percentile": 118.81, "90th_percentile": 118.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 162.75, "10th_percentile": 162.75, "90th_percentile": 162.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 162.75, "10th_percentile": 162.75, "90th_percentile": 162.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 162.75, "10th_percentile": 162.75, "90th_percentile": 162.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "ALLERGIC REACTIONS WITH MCC", "code_information": [ { "code": "915", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 11965.98, "maximum": 20559.24, "setting": "inpatient", "gross_charge": 50493.5, "discounted_cash": 35345.45, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_percentage": 19.3, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 9745.69, "10th_percentile": 9745.69, "90th_percentile": 9745.69, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_percentage": 34.5, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; Inpatient; 34.5% Billed", "median_amount": 17421.03, "10th_percentile": 17421.03, "90th_percentile": 17421.03, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_percentage": 36.1, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; Inpatient; 36.1% Billed", "median_amount": 18228.97, "10th_percentile": 18228.97, "90th_percentile": 18228.97, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; Stop Loss; 70% Billed", "median_amount": 35347.03, "10th_percentile": 35347.03, "90th_percentile": 35347.03, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_percentage": 73.0, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All Inpatient Services; 73% Billed", "median_amount": 36861.9, "10th_percentile": 36861.9, "90th_percentile": 36861.9, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; Inpatient Services; 50% Billed", "median_amount": 25247.88, "10th_percentile": 25247.88, "90th_percentile": 25247.88, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; Inpatient; 30.35% Billed", "median_amount": 15325.46, "10th_percentile": 15325.46, "90th_percentile": 15325.46, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; 100% Billed", "median_amount": 50495.75, "10th_percentile": 50495.75, "90th_percentile": 50495.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_percentage": 50.8, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; Inpatient; 50.8% Billed", "median_amount": 25651.84, "10th_percentile": 25651.84, "90th_percentile": 25651.84, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 71.3, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; IP Services. ADP RATE (for patient estimates only); 71.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36003.47, "10th_percentile": 36003.47, "90th_percentile": 36003.47, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; Inpatient; 80% Billed", "median_amount": 40396.6, "10th_percentile": 40396.6, "90th_percentile": 40396.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 37871.81, "10th_percentile": 37871.81, "90th_percentile": 37871.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 20559.24, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 20559.24, "10th_percentile": 20559.24, "90th_percentile": 20559.24, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 13187.11, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 13187.11, "10th_percentile": 13187.11, "90th_percentile": 13187.11, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 13451.12, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 7,999.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 13451.12, "10th_percentile": 13451.12, "90th_percentile": 13451.12, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 13716.81, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 8,157.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 76531.5, "10th_percentile": 76531.5, "90th_percentile": 76531.5, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 13187.11, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 13187.11, "10th_percentile": 13187.11, "90th_percentile": 13187.11, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 20559.24, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 20559.24, "10th_percentile": 20559.24, "90th_percentile": 20559.24, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 13187.11, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 13187.11, "10th_percentile": 13187.11, "90th_percentile": 13187.11, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_dollar": 11965.98, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.68, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $13,572.05; Total: $13,572.05", "median_amount": 13572.05, "10th_percentile": 13572.05, "90th_percentile": 13572.05, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.68, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $13,572.05; Total: $13,572.05" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 11965.98, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.68, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $13,572.05; Total: $13,572.05 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13572.05, "10th_percentile": 13572.05, "90th_percentile": 13572.05, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.68, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $13,572.05; Total: $13,572.05 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_dollar": 11965.98, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.68, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $13,572.05; Total: $13,572.05 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13572.05, "10th_percentile": 13572.05, "90th_percentile": 13572.05, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.68, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $13,572.05; Total: $13,572.05 Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 18290.76, "standard_charge_algorithm": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 63% of charges. Total pmt for all lines paid so far is less than 63% of claim billed amount.", "median_amount": 18290.76, "10th_percentile": 18290.76, "90th_percentile": 18290.76, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.768147455; Using historical claim(s); Scope: All Financial Classes; Cases: 10; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 63% of charges. Total pmt for all lines paid so far is less than 63% of claim billed amount." } ] } ] }, { "description": "ALLOGRAFT DERMIS 1MM CORTIVA 8X16CM", "code_information": [ { "code": "SUP-339142", "type": "CDM" }, { "code": "C1762", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 2242.95, "10th_percentile": 2242.95, "90th_percentile": 2242.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" } ] } ] }, { "description": "ALLOGRAFT PROT NERVE AXOGUARD 3.5X40MM", "code_information": [ { "code": "SUP-336731", "type": "CDM" }, { "code": "C1763", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1862.02, "maximum": 9647.76, "setting": "outpatient", "gross_charge": 9647.76, "discounted_cash": 6753.43, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 3442.32, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3442.32, "10th_percentile": 3442.32, "90th_percentile": 3442.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 3270.59, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3270.59, "10th_percentile": 3270.59, "90th_percentile": 3270.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 2817.15, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2817.15, "10th_percentile": 2817.15, "90th_percentile": 2817.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 2817.15, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2817.15, "10th_percentile": 2817.15, "90th_percentile": 2817.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 3424.95, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 3424.95, "10th_percentile": 3424.95, "90th_percentile": 3424.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 1862.02, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1862.02, "10th_percentile": 1862.02, "90th_percentile": 1862.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 3318.83, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 3318.83, "10th_percentile": 3318.83, "90th_percentile": 3318.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 7718.21, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 7718.21, "10th_percentile": 7718.21, "90th_percentile": 7718.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9647.76, "10th_percentile": 9647.76, "90th_percentile": 9647.76, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9647.76, "10th_percentile": 9647.76, "90th_percentile": 9647.76, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4611.63, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4611.63, "10th_percentile": 4611.63, "90th_percentile": 4611.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4611.63, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4611.63, "10th_percentile": 4611.63, "90th_percentile": 4611.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4611.63, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4611.63, "10th_percentile": 4611.63, "90th_percentile": 4611.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 3442.32, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3442.32, "10th_percentile": 3442.32, "90th_percentile": 3442.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 3270.59, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3270.59, "10th_percentile": 3270.59, "90th_percentile": 3270.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 5132.61, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 5132.61, "10th_percentile": 5132.61, "90th_percentile": 5132.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 9647.76, "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 $9,647.76 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 9647.76, "10th_percentile": 9647.76, "90th_percentile": 9647.76, "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 $9,647.76 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 6078.09, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $6,078.09 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 6078.09, "10th_percentile": 6078.09, "90th_percentile": 6078.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $6,078.09 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 2981.16, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2981.16, "10th_percentile": 2981.16, "90th_percentile": 2981.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 1900.61, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1900.61, "10th_percentile": 1900.61, "90th_percentile": 1900.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 6196.76, "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": 6196.76, "10th_percentile": 6196.76, "90th_percentile": 6196.76, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 7235.82, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 7235.82, "10th_percentile": 7235.82, "90th_percentile": 7235.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 5084.37, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5084.37, "10th_percentile": 5084.37, "90th_percentile": 5084.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 6753.43, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 6753.43, "10th_percentile": 6753.43, "90th_percentile": 6753.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 9647.76, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9647.76, "10th_percentile": 9647.76, "90th_percentile": 9647.76, "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": "NWR HFN PPO", "standard_charge_dollar": 7042.86, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 7042.86, "10th_percentile": 7042.86, "90th_percentile": 7042.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 2928.1, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 2928.1, "10th_percentile": 2928.1, "90th_percentile": 2928.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 4573.04, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 4573.04, "10th_percentile": 4573.04, "90th_percentile": 4573.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 4823.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 4823.88, "10th_percentile": 4823.88, "90th_percentile": 4823.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $9,647.76 @ 12.5% = $1,205.97 due to $0.00 Claim Price", "median_amount": 1205.97, "10th_percentile": 1205.97, "90th_percentile": 1205.97, "count": "0", "methodology": "other", "additional_payer_notes": "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: $9,647.76 @ 12.5% = $1,205.97 due to $0.00 Claim Price" } ] } ] }, { "description": "ALLOGRAFT TRIAD CC LORDOTIC 6X11X14MM", "code_information": [ { "code": "SUP-336922", "type": "CDM" }, { "code": "C1734", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 514.77, "maximum": 2667.2, "setting": "outpatient", "gross_charge": 2667.2, "discounted_cash": 1867.04, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1274.92, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1274.92, "10th_percentile": 1274.92, "90th_percentile": 1274.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1274.92, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1274.92, "10th_percentile": 1274.92, "90th_percentile": 1274.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1274.92, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1274.92, "10th_percentile": 1274.92, "90th_percentile": 1274.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 951.66, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 951.66, "10th_percentile": 951.66, "90th_percentile": 951.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 951.66, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 951.66, "10th_percentile": 951.66, "90th_percentile": 951.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 778.82, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 778.82, "10th_percentile": 778.82, "90th_percentile": 778.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 778.82, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 778.82, "10th_percentile": 778.82, "90th_percentile": 778.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 904.18, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 904.18, "10th_percentile": 904.18, "90th_percentile": 904.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 904.18, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 904.18, "10th_percentile": 904.18, "90th_percentile": 904.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1418.95, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1418.95, "10th_percentile": 1418.95, "90th_percentile": 1418.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2667.2, "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 $2,667.20 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2667.2, "10th_percentile": 2667.2, "90th_percentile": 2667.2, "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 $2,667.20 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 824.16, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 824.16, "10th_percentile": 824.16, "90th_percentile": 824.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 946.86, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 946.86, "10th_percentile": 946.86, "90th_percentile": 946.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 525.44, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 525.44, "10th_percentile": 525.44, "90th_percentile": 525.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 514.77, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 514.77, "10th_percentile": 514.77, "90th_percentile": 514.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 917.52, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 917.52, "10th_percentile": 917.52, "90th_percentile": 917.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2000.4, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 2000.4, "10th_percentile": 2000.4, "90th_percentile": 2000.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 2133.76, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2133.76, "10th_percentile": 2133.76, "90th_percentile": 2133.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2667.2, "10th_percentile": 2667.2, "90th_percentile": 2667.2, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2667.2, "10th_percentile": 2667.2, "90th_percentile": 2667.2, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1405.61, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1405.61, "10th_percentile": 1405.61, "90th_percentile": 1405.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 1680.34, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,680.34 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1680.34, "10th_percentile": 1680.34, "90th_percentile": 1680.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,680.34 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 1713.14, "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": 1713.14, "10th_percentile": 1713.14, "90th_percentile": 1713.14, "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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 2667.2, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2667.2, "10th_percentile": 2667.2, "90th_percentile": 2667.2, "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": "NWR HFN PPO", "standard_charge_dollar": 1947.06, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1947.06, "10th_percentile": 1947.06, "90th_percentile": 1947.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 809.5, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 809.5, "10th_percentile": 809.5, "90th_percentile": 809.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1333.6, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1333.6, "10th_percentile": 1333.6, "90th_percentile": 1333.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1867.04, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1867.04, "10th_percentile": 1867.04, "90th_percentile": 1867.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 1264.25, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1264.25, "10th_percentile": 1264.25, "90th_percentile": 1264.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $2,667.20 @ 12.5% = $333.40 due to $0.00 Claim Price", "median_amount": 333.4, "10th_percentile": 333.4, "90th_percentile": 333.4, "count": "0", "methodology": "other", "additional_payer_notes": "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: $2,667.20 @ 12.5% = $333.40 due to $0.00 Claim Price" } ] } ] }, { "description": "ALLOPURINOL 50 MG ORAL HALF TAB", "drug_information": { "unit": 50.0, "type": "ME" }, "code_information": [ { "code": "RX-4080000002", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00000-0100-02", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR 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": "NWR BLUE CROSS MEDICARE ADVT", "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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "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": "51079-0205-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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": "NWR 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR BLUE CROSS MEDICARE ADVT", "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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% 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": "51079-0205-20", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR 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": "NWR BLUE CROSS MEDICARE ADVT", "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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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 0.25 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": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR 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": "NWR BLUE CROSS MEDICARE ADVT", "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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR 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": "NWR BLUE CROSS MEDICARE ADVT", "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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "AMANTADINE HCL 100 MG ORAL CAP", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-364", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "68382-0512-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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": "NWR 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": "GLOBAL EXCEL [1712]", "plan_name": "NWR 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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR BLUE CROSS MEDICARE ADVT", "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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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": "HEALTHLINK [125]", "plan_name": "NWR 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": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" } ] } ] }, { "description": "AMANTADINE HCL 50 MG/5 ML ORAL SOLN", "drug_information": { "unit": 473.0, "type": "ML" }, "code_information": [ { "code": "RX-365", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00121-0646-16", "type": "NDC" } ], "standard_charges": [ { "minimum": 27.45, "maximum": 142.25, "setting": "outpatient", "gross_charge": 142.25, "discounted_cash": 99.57, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 142.25, "10th_percentile": 142.25, "90th_percentile": 142.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 106.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 106.69, "10th_percentile": 106.69, "90th_percentile": 106.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 74.97, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 74.97, "10th_percentile": 74.97, "90th_percentile": 74.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 43.96, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.96, "10th_percentile": 43.96, "90th_percentile": 43.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 103.84, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 103.84, "10th_percentile": 103.84, "90th_percentile": 103.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 67.43, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 67.43, "10th_percentile": 67.43, "90th_percentile": 67.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 91.37, "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": 91.37, "10th_percentile": 91.37, "90th_percentile": 91.37, "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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 43.17, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 43.17, "10th_percentile": 43.17, "90th_percentile": 43.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 99.58, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 99.58, "10th_percentile": 99.58, "90th_percentile": 99.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 71.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 71.13, "10th_percentile": 71.13, "90th_percentile": 71.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 142.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 142.25, "10th_percentile": 142.25, "90th_percentile": 142.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 28.02, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.02, "10th_percentile": 28.02, "90th_percentile": 28.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 89.62, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $89.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 89.62, "10th_percentile": 89.62, "90th_percentile": 89.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $89.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 142.25, "10th_percentile": 142.25, "90th_percentile": 142.25, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 142.25, "10th_percentile": 142.25, "90th_percentile": 142.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 69.28, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 69.28, "10th_percentile": 69.28, "90th_percentile": 69.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 27.45, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 27.45, "10th_percentile": 27.45, "90th_percentile": 27.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 50.5, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 50.5, "10th_percentile": 50.5, "90th_percentile": 50.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 74.68, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 74.68, "10th_percentile": 74.68, "90th_percentile": 74.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 48.93, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 48.93, "10th_percentile": 48.93, "90th_percentile": 48.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 75.68, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 75.68, "10th_percentile": 75.68, "90th_percentile": 75.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 41.95, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41.95, "10th_percentile": 41.95, "90th_percentile": 41.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 113.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 113.8, "10th_percentile": 113.8, "90th_percentile": 113.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 142.25, "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 $142.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 142.25, "10th_percentile": 142.25, "90th_percentile": 142.25, "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 $142.25 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": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 39.96, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.96, "10th_percentile": 39.96, "90th_percentile": 39.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 39.96, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.96, "10th_percentile": 39.96, "90th_percentile": 39.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 50.75, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.75, "10th_percentile": 50.75, "90th_percentile": 50.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 50.75, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.75, "10th_percentile": 50.75, "90th_percentile": 50.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 55.41, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.41, "10th_percentile": 55.41, "90th_percentile": 55.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 55.41, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.41, "10th_percentile": 55.41, "90th_percentile": 55.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "AMINO AC 4.25% NO.1-D5W-LYTES 4.25 % IV SOLP", "drug_information": { "unit": 2000.0, "type": "ML" }, "code_information": [ { "code": "RX-238407", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "00338-7024-04", "type": "NDC" } ], "standard_charges": [ { "minimum": 79.08, "maximum": 409.75, "setting": "outpatient", "gross_charge": 409.75, "discounted_cash": 286.82, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 409.75, "10th_percentile": 409.75, "90th_percentile": 409.75, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 409.75, "10th_percentile": 409.75, "90th_percentile": 409.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 409.75, "10th_percentile": 409.75, "90th_percentile": 409.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 146.2, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 146.2, "10th_percentile": 146.2, "90th_percentile": 146.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 146.2, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 146.2, "10th_percentile": 146.2, "90th_percentile": 146.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 159.6, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 159.6, "10th_percentile": 159.6, "90th_percentile": 159.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 159.6, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 159.6, "10th_percentile": 159.6, "90th_percentile": 159.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 115.1, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 115.1, "10th_percentile": 115.1, "90th_percentile": 115.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 115.1, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 115.1, "10th_percentile": 115.1, "90th_percentile": 115.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 79.08, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 79.08, "10th_percentile": 79.08, "90th_percentile": 79.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 145.46, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 145.46, "10th_percentile": 145.46, "90th_percentile": 145.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 215.12, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 215.12, "10th_percentile": 215.12, "90th_percentile": 215.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 140.95, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 140.95, "10th_percentile": 140.95, "90th_percentile": 140.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 199.55, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 199.55, "10th_percentile": 199.55, "90th_percentile": 199.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 299.12, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 299.12, "10th_percentile": 299.12, "90th_percentile": 299.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 327.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 327.8, "10th_percentile": 327.8, "90th_percentile": 327.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 204.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 204.88, "10th_percentile": 204.88, "90th_percentile": 204.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 217.99, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 217.99, "10th_percentile": 217.99, "90th_percentile": 217.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 120.84, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 120.84, "10th_percentile": 120.84, "90th_percentile": 120.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 80.72, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 80.72, "10th_percentile": 80.72, "90th_percentile": 80.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC CORE", "standard_charge_dollar": 194.22, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 194.22, "10th_percentile": 194.22, "90th_percentile": 194.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 263.18, "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": 263.18, "10th_percentile": 263.18, "90th_percentile": 263.18, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 307.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 307.31, "10th_percentile": 307.31, "90th_percentile": 307.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 126.61, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 126.61, "10th_percentile": 126.61, "90th_percentile": 126.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 124.36, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 124.36, "10th_percentile": 124.36, "90th_percentile": 124.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 286.83, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 286.83, "10th_percentile": 286.83, "90th_percentile": 286.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 409.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 409.75, "10th_percentile": 409.75, "90th_percentile": 409.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 215.94, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 215.94, "10th_percentile": 215.94, "90th_percentile": 215.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 409.75, "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 $409.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 409.75, "10th_percentile": 409.75, "90th_percentile": 409.75, "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 $409.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 258.14, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $258.14 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 258.14, "10th_percentile": 258.14, "90th_percentile": 258.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $258.14 so that total pmt for all claim lines does not exceed 63% of claim billed amount." } ] } ] }, { "description": "AMINO AC 8 %-D10W-ELECTROLYTES 8-10 % IV SOLP", "drug_information": { "unit": 2000.0, "type": "ML" }, "code_information": [ { "code": "RX-227243", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "00338-0214-04", "type": "NDC" } ], "standard_charges": [ { "minimum": 121.25, "maximum": 628.25, "setting": "outpatient", "gross_charge": 628.25, "discounted_cash": 439.77, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 185.27, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 185.27, "10th_percentile": 185.27, "90th_percentile": 185.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 502.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 502.6, "10th_percentile": 502.6, "90th_percentile": 502.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 329.83, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 329.83, "10th_percentile": 329.83, "90th_percentile": 329.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 216.12, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 216.12, "10th_percentile": 216.12, "90th_percentile": 216.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 305.96, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 305.96, "10th_percentile": 305.96, "90th_percentile": 305.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 223.03, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 223.03, "10th_percentile": 223.03, "90th_percentile": 223.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 121.25, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 121.25, "10th_percentile": 121.25, "90th_percentile": 121.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 176.48, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.48, "10th_percentile": 176.48, "90th_percentile": 176.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 224.16, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 224.16, "10th_percentile": 224.16, "90th_percentile": 224.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 244.7, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 244.7, "10th_percentile": 244.7, "90th_percentile": 244.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 628.25, "10th_percentile": 628.25, "90th_percentile": 628.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 628.25, "10th_percentile": 628.25, "90th_percentile": 628.25, "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": "NWR BCBS PPO", "standard_charge_dollar": 244.7, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 244.7, "10th_percentile": 244.7, "90th_percentile": 244.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 224.16, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 224.16, "10th_percentile": 224.16, "90th_percentile": 224.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 176.48, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 176.48, "10th_percentile": 176.48, "90th_percentile": 176.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 403.52, "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": 403.52, "10th_percentile": 403.52, "90th_percentile": 403.52, "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": "NWR UHC CORE", "standard_charge_dollar": 297.79, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 297.79, "10th_percentile": 297.79, "90th_percentile": 297.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 190.67, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 190.67, "10th_percentile": 190.67, "90th_percentile": 190.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 331.09, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 331.09, "10th_percentile": 331.09, "90th_percentile": 331.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 628.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 628.25, "10th_percentile": 628.25, "90th_percentile": 628.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 194.13, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 194.13, "10th_percentile": 194.13, "90th_percentile": 194.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 439.78, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 439.78, "10th_percentile": 439.78, "90th_percentile": 439.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 458.62, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 458.62, "10th_percentile": 458.62, "90th_percentile": 458.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 314.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 314.13, "10th_percentile": 314.13, "90th_percentile": 314.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 334.23, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 334.23, "10th_percentile": 334.23, "90th_percentile": 334.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 471.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 471.19, "10th_percentile": 471.19, "90th_percentile": 471.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 123.77, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 123.77, "10th_percentile": 123.77, "90th_percentile": 123.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 395.8, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $395.80 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 395.8, "10th_percentile": 395.8, "90th_percentile": 395.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $395.80 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 628.25, "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 $628.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 628.25, "10th_percentile": 628.25, "90th_percentile": 628.25, "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 $628.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 628.25, "10th_percentile": 628.25, "90th_percentile": 628.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "AMINO ACIDS 5 %-LYTES-CA-DEXT 15 % IV SOLP", "drug_information": { "unit": 2000.0, "type": "ML" }, "code_information": [ { "code": "RX-87724", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "00338-7032-04", "type": "NDC" } ], "standard_charges": [ { "minimum": 92.25, "maximum": 478.0, "setting": "outpatient", "gross_charge": 478.0, "discounted_cash": 334.6, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 478.0, "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 $478.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 478.0, "10th_percentile": 478.0, "90th_percentile": 478.0, "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 $478.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 301.14, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $301.14 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 301.14, "10th_percentile": 301.14, "90th_percentile": 301.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $301.14 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 145.07, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 145.07, "10th_percentile": 145.07, "90th_percentile": 145.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 478.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 478.0, "10th_percentile": 478.0, "90th_percentile": 478.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 358.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 358.5, "10th_percentile": 358.5, "90th_percentile": 358.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 239.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 239.0, "10th_percentile": 239.0, "90th_percentile": 239.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 94.17, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 94.17, "10th_percentile": 94.17, "90th_percentile": 94.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC CORE", "standard_charge_dollar": 226.57, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 226.57, "10th_percentile": 226.57, "90th_percentile": 226.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 254.3, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 254.3, "10th_percentile": 254.3, "90th_percentile": 254.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 140.96, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 140.96, "10th_percentile": 140.96, "90th_percentile": 140.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 307.02, "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": 307.02, "10th_percentile": 307.02, "90th_percentile": 307.02, "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": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 251.91, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 251.91, "10th_percentile": 251.91, "90th_percentile": 251.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 147.7, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 147.7, "10th_percentile": 147.7, "90th_percentile": 147.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 334.6, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 334.6, "10th_percentile": 334.6, "90th_percentile": 334.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 348.94, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 348.94, "10th_percentile": 348.94, "90th_percentile": 348.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 382.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 382.4, "10th_percentile": 382.4, "90th_percentile": 382.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 250.95, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 250.95, "10th_percentile": 250.95, "90th_percentile": 250.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 164.43, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 164.43, "10th_percentile": 164.43, "90th_percentile": 164.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 232.79, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 232.79, "10th_percentile": 232.79, "90th_percentile": 232.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 169.69, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 169.69, "10th_percentile": 169.69, "90th_percentile": 169.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 92.25, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 92.25, "10th_percentile": 92.25, "90th_percentile": 92.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 134.27, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 134.27, "10th_percentile": 134.27, "90th_percentile": 134.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 134.27, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 134.27, "10th_percentile": 134.27, "90th_percentile": 134.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 170.55, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 170.55, "10th_percentile": 170.55, "90th_percentile": 170.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 170.55, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 170.55, "10th_percentile": 170.55, "90th_percentile": 170.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 186.18, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 186.18, "10th_percentile": 186.18, "90th_percentile": 186.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 186.18, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 186.18, "10th_percentile": 186.18, "90th_percentile": 186.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 478.0, "10th_percentile": 478.0, "90th_percentile": 478.0, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 478.0, "10th_percentile": 478.0, "90th_percentile": 478.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 478.0, "10th_percentile": 478.0, "90th_percentile": 478.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "AMINO ACIDS 8 %-LYTES-CA-DEXT 14 % IV SOLP", "drug_information": { "unit": 2000.0, "type": "ML" }, "code_information": [ { "code": "RX-227242", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "00338-0206-04", "type": "NDC" } ], "standard_charges": [ { "minimum": 139.68, "maximum": 723.75, "setting": "outpatient", "gross_charge": 723.75, "discounted_cash": 506.62, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 723.75, "10th_percentile": 723.75, "90th_percentile": 723.75, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 723.75, "10th_percentile": 723.75, "90th_percentile": 723.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 723.75, "10th_percentile": 723.75, "90th_percentile": 723.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 258.23, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 258.23, "10th_percentile": 258.23, "90th_percentile": 258.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 258.23, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 258.23, "10th_percentile": 258.23, "90th_percentile": 258.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 281.9, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 281.9, "10th_percentile": 281.9, "90th_percentile": 281.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 281.9, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 281.9, "10th_percentile": 281.9, "90th_percentile": 281.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 203.3, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 203.3, "10th_percentile": 203.3, "90th_percentile": 203.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 203.3, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 203.3, "10th_percentile": 203.3, "90th_percentile": 203.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 139.68, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 139.68, "10th_percentile": 139.68, "90th_percentile": 139.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 256.93, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 256.93, "10th_percentile": 256.93, "90th_percentile": 256.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 379.97, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 379.97, "10th_percentile": 379.97, "90th_percentile": 379.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 248.97, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 248.97, "10th_percentile": 248.97, "90th_percentile": 248.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 352.47, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 352.47, "10th_percentile": 352.47, "90th_percentile": 352.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 528.34, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 528.34, "10th_percentile": 528.34, "90th_percentile": 528.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 579.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 579.0, "10th_percentile": 579.0, "90th_percentile": 579.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 361.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 361.88, "10th_percentile": 361.88, "90th_percentile": 361.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 385.04, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 385.04, "10th_percentile": 385.04, "90th_percentile": 385.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 213.43, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 213.43, "10th_percentile": 213.43, "90th_percentile": 213.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 142.58, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 142.58, "10th_percentile": 142.58, "90th_percentile": 142.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC CORE", "standard_charge_dollar": 343.06, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 343.06, "10th_percentile": 343.06, "90th_percentile": 343.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 464.86, "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": 464.86, "10th_percentile": 464.86, "90th_percentile": 464.86, "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": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 542.81, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 542.81, "10th_percentile": 542.81, "90th_percentile": 542.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 223.64, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 223.64, "10th_percentile": 223.64, "90th_percentile": 223.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 219.66, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 219.66, "10th_percentile": 219.66, "90th_percentile": 219.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 506.63, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 506.63, "10th_percentile": 506.63, "90th_percentile": 506.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 723.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 723.75, "10th_percentile": 723.75, "90th_percentile": 723.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 381.42, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 381.42, "10th_percentile": 381.42, "90th_percentile": 381.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 723.75, "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 $723.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 723.75, "10th_percentile": 723.75, "90th_percentile": 723.75, "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 $723.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 455.96, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $455.96 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 455.96, "10th_percentile": 455.96, "90th_percentile": 455.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $455.96 so that total pmt for all claim lines does not exceed 63% of claim billed amount." } ] } ] }, { "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": 14.38, "maximum": 74.5, "setting": "outpatient", "gross_charge": 74.5, "discounted_cash": 52.15, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 74.5, "10th_percentile": 74.5, "90th_percentile": 74.5, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 74.5, "10th_percentile": 74.5, "90th_percentile": 74.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $74.50 @ 12.5% = $9.31 due to $0.00 Claim Price", "median_amount": 9.31, "10th_percentile": 9.31, "90th_percentile": 9.31, "count": "0", "methodology": "other", "additional_payer_notes": "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: $74.50 @ 12.5% = $9.31 due to $0.00 Claim Price" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 46.94, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $46.94 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 46.94, "10th_percentile": 46.94, "90th_percentile": 46.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $46.94 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 74.5, "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 $74.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 74.5, "10th_percentile": 74.5, "90th_percentile": 74.5, "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 $74.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 14.38, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 14.38, "10th_percentile": 14.38, "90th_percentile": 14.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 25.63, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 25.63, "10th_percentile": 25.63, "90th_percentile": 25.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 74.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 74.5, "10th_percentile": 74.5, "90th_percentile": 74.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 39.63, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 39.63, "10th_percentile": 39.63, "90th_percentile": 39.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 59.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 59.6, "10th_percentile": 59.6, "90th_percentile": 59.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 26.45, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 26.45, "10th_percentile": 26.45, "90th_percentile": 26.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 55.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 55.88, "10th_percentile": 55.88, "90th_percentile": 55.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 37.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 37.25, "10th_percentile": 37.25, "90th_percentile": 37.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 54.39, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 54.39, "10th_percentile": 54.39, "90th_percentile": 54.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 22.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 22.61, "10th_percentile": 22.61, "90th_percentile": 22.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 52.15, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 52.15, "10th_percentile": 52.15, "90th_percentile": 52.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 39.11, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.11, "10th_percentile": 39.11, "90th_percentile": 39.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 25.26, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.26, "10th_percentile": 25.26, "90th_percentile": 25.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 25.26, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.26, "10th_percentile": 25.26, "90th_percentile": 25.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 26.58, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.58, "10th_percentile": 26.58, "90th_percentile": 26.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 26.58, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.58, "10th_percentile": 26.58, "90th_percentile": 26.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 35.61, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.61, "10th_percentile": 35.61, "90th_percentile": 35.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 35.61, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.61, "10th_percentile": 35.61, "90th_percentile": 35.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 35.61, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.61, "10th_percentile": 35.61, "90th_percentile": 35.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "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": "00409-5922-16", "type": "NDC" } ], "standard_charges": [ { "minimum": 14.38, "maximum": 74.5, "setting": "outpatient", "gross_charge": 74.5, "discounted_cash": 52.15, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $74.50 @ 12.5% = $9.31 due to $0.00 Claim Price", "median_amount": 9.31, "10th_percentile": 9.31, "90th_percentile": 9.31, "count": "0", "methodology": "other", "additional_payer_notes": "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: $74.50 @ 12.5% = $9.31 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 74.5, "10th_percentile": 74.5, "90th_percentile": 74.5, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 74.5, "10th_percentile": 74.5, "90th_percentile": 74.5, "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 35.61, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.61, "10th_percentile": 35.61, "90th_percentile": 35.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 35.61, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.61, "10th_percentile": 35.61, "90th_percentile": 35.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 35.61, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.61, "10th_percentile": 35.61, "90th_percentile": 35.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 26.58, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.58, "10th_percentile": 26.58, "90th_percentile": 26.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 26.58, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.58, "10th_percentile": 26.58, "90th_percentile": 26.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 25.26, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.26, "10th_percentile": 25.26, "90th_percentile": 25.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 25.26, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.26, "10th_percentile": 25.26, "90th_percentile": 25.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 26.45, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 26.45, "10th_percentile": 26.45, "90th_percentile": 26.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 25.63, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 25.63, "10th_percentile": 25.63, "90th_percentile": 25.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 55.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 55.88, "10th_percentile": 55.88, "90th_percentile": 55.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 39.11, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.11, "10th_percentile": 39.11, "90th_percentile": 39.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 54.39, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 54.39, "10th_percentile": 54.39, "90th_percentile": 54.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 59.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 59.6, "10th_percentile": 59.6, "90th_percentile": 59.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 14.38, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 14.38, "10th_percentile": 14.38, "90th_percentile": 14.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 52.15, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 52.15, "10th_percentile": 52.15, "90th_percentile": 52.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 39.63, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 39.63, "10th_percentile": 39.63, "90th_percentile": 39.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 74.5, "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 $74.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 74.5, "10th_percentile": 74.5, "90th_percentile": 74.5, "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 $74.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 37.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 37.25, "10th_percentile": 37.25, "90th_percentile": 37.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 74.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 74.5, "10th_percentile": 74.5, "90th_percentile": 74.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 22.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 22.61, "10th_percentile": 22.61, "90th_percentile": 22.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 46.94, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $46.94 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 46.94, "10th_percentile": 46.94, "90th_percentile": 46.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $46.94 so that total pmt for all claim lines does not exceed 63% of claim billed amount." } ] } ] }, { "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": 1.98, "maximum": 10.25, "setting": "outpatient", "gross_charge": 10.25, "discounted_cash": 7.17, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 10.25, "10th_percentile": 10.25, "90th_percentile": 10.25, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 10.25, "10th_percentile": 10.25, "90th_percentile": 10.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $10.25 @ 12.5% = $1.28 due to $0.00 Claim Price", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "other", "additional_payer_notes": "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: $10.25 @ 12.5% = $1.28 due to $0.00 Claim Price" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 6.46, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $6.46 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 6.46, "10th_percentile": 6.46, "90th_percentile": 6.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $6.46 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 10.25, "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 $10.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 10.25, "10th_percentile": 10.25, "90th_percentile": 10.25, "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 $10.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 1.98, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1.98, "10th_percentile": 1.98, "90th_percentile": 1.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 3.53, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 3.53, "10th_percentile": 3.53, "90th_percentile": 3.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 10.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 10.25, "10th_percentile": 10.25, "90th_percentile": 10.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 5.45, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 5.45, "10th_percentile": 5.45, "90th_percentile": 5.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 8.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 8.2, "10th_percentile": 8.2, "90th_percentile": 8.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 3.64, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 3.64, "10th_percentile": 3.64, "90th_percentile": 3.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 7.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 7.69, "10th_percentile": 7.69, "90th_percentile": 7.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 5.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 5.13, "10th_percentile": 5.13, "90th_percentile": 5.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 7.48, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 7.48, "10th_percentile": 7.48, "90th_percentile": 7.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 3.11, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 3.11, "10th_percentile": 3.11, "90th_percentile": 3.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 7.18, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% 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; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 5.38, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.38, "10th_percentile": 5.38, "90th_percentile": 5.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 3.47, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.47, "10th_percentile": 3.47, "90th_percentile": 3.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 3.47, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.47, "10th_percentile": 3.47, "90th_percentile": 3.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 3.66, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.66, "10th_percentile": 3.66, "90th_percentile": 3.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 3.66, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.66, "10th_percentile": 3.66, "90th_percentile": 3.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4.9, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.9, "10th_percentile": 4.9, "90th_percentile": 4.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4.9, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.9, "10th_percentile": 4.9, "90th_percentile": 4.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4.9, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.9, "10th_percentile": 4.9, "90th_percentile": 4.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "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": "67457-0153-03", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.63, "maximum": 24.0, "setting": "outpatient", "gross_charge": 24.0, "discounted_cash": 16.8, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $24.00 @ 12.5% = $3.00 due to $0.00 Claim Price", "median_amount": 3.0, "10th_percentile": 3.0, "90th_percentile": 3.0, "count": "0", "methodology": "other", "additional_payer_notes": "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: $24.00 @ 12.5% = $3.00 due to $0.00 Claim Price" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 18.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 18.0, "10th_percentile": 18.0, "90th_percentile": 18.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 7.28, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 7.28, "10th_percentile": 7.28, "90th_percentile": 7.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 12.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 17.52, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 17.52, "10th_percentile": 17.52, "90th_percentile": 17.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 24.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 24.0, "10th_percentile": 24.0, "90th_percentile": 24.0, "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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 16.8, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 16.8, "10th_percentile": 16.8, "90th_percentile": 16.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 12.77, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 12.77, "10th_percentile": 12.77, "90th_percentile": 12.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 15.12, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $15.12 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 15.12, "10th_percentile": 15.12, "90th_percentile": 15.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $15.12 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.0, "10th_percentile": 24.0, "90th_percentile": 24.0, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.0, "10th_percentile": 24.0, "90th_percentile": 24.0, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 24.0, "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 $24.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 24.0, "10th_percentile": 24.0, "90th_percentile": 24.0, "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 $24.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 4.63, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 4.63, "10th_percentile": 4.63, "90th_percentile": 4.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 8.26, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 8.26, "10th_percentile": 8.26, "90th_percentile": 8.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 19.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 19.2, "10th_percentile": 19.2, "90th_percentile": 19.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 8.52, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 8.52, "10th_percentile": 8.52, "90th_percentile": 8.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 12.6, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.6, "10th_percentile": 12.6, "90th_percentile": 12.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 8.14, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.14, "10th_percentile": 8.14, "90th_percentile": 8.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 8.14, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.14, "10th_percentile": 8.14, "90th_percentile": 8.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 8.56, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.56, "10th_percentile": 8.56, "90th_percentile": 8.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 8.56, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.56, "10th_percentile": 8.56, "90th_percentile": 8.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 11.47, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 11.47, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 11.47, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "AMIODARONE 50 MG/ML IV SOLN", "drug_information": { "unit": 18.0, "type": "ML" }, "code_information": [ { "code": "RX-9065", "type": "CDM" }, { "code": "J0282", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "67457-0153-18", "type": "NDC" } ], "standard_charges": [ { "minimum": 17.95, "maximum": 93.0, "setting": "outpatient", "gross_charge": 93.0, "discounted_cash": 65.1, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $93.00 @ 12.5% = $11.63 due to $0.00 Claim Price", "median_amount": 11.63, "10th_percentile": 11.63, "90th_percentile": 11.63, "count": "0", "methodology": "other", "additional_payer_notes": "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: $93.00 @ 12.5% = $11.63 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 93.0, "10th_percentile": 93.0, "90th_percentile": 93.0, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 93.0, "10th_percentile": 93.0, "90th_percentile": 93.0, "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 44.45, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 44.45, "10th_percentile": 44.45, "90th_percentile": 44.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 44.45, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 44.45, "10th_percentile": 44.45, "90th_percentile": 44.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 44.45, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 44.45, "10th_percentile": 44.45, "90th_percentile": 44.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 33.18, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.18, "10th_percentile": 33.18, "90th_percentile": 33.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 33.18, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.18, "10th_percentile": 33.18, "90th_percentile": 33.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 31.53, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.53, "10th_percentile": 31.53, "90th_percentile": 31.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 31.53, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.53, "10th_percentile": 31.53, "90th_percentile": 31.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 33.02, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 33.02, "10th_percentile": 33.02, "90th_percentile": 33.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 31.99, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 31.99, "10th_percentile": 31.99, "90th_percentile": 31.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 69.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 69.75, "10th_percentile": 69.75, "90th_percentile": 69.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 28.23, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 28.23, "10th_percentile": 28.23, "90th_percentile": 28.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 46.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 46.5, "10th_percentile": 46.5, "90th_percentile": 46.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 48.83, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 48.83, "10th_percentile": 48.83, "90th_percentile": 48.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 67.89, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 67.89, "10th_percentile": 67.89, "90th_percentile": 67.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 74.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 74.4, "10th_percentile": 74.4, "90th_percentile": 74.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 93.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 93.0, "10th_percentile": 93.0, "90th_percentile": 93.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 17.95, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 17.95, "10th_percentile": 17.95, "90th_percentile": 17.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 65.1, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 65.1, "10th_percentile": 65.1, "90th_percentile": 65.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 49.48, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 49.48, "10th_percentile": 49.48, "90th_percentile": 49.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 93.0, "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 $93.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 93.0, "10th_percentile": 93.0, "90th_percentile": 93.0, "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 $93.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 58.59, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $58.59 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 58.59, "10th_percentile": 58.59, "90th_percentile": 58.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $58.59 so that total pmt for all claim lines does not exceed 63% of claim billed amount." } ] } ] }, { "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": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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": "NWR 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": "GLOBAL EXCEL [1712]", "plan_name": "NWR 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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR BLUE CROSS MEDICARE ADVT", "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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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": "HEALTHLINK [125]", "plan_name": "NWR 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": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% 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": "50268-0037-11", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.53, "maximum": 2.75, "setting": "outpatient", "gross_charge": 2.75, "discounted_cash": 1.92, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.98, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.98, "10th_percentile": 0.98, "90th_percentile": 0.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.95, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1.44, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.53, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.53, "10th_percentile": 0.53, "90th_percentile": 0.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.54, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.45, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.45, "10th_percentile": 1.45, "90th_percentile": 1.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.83, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.83, "10th_percentile": 0.83, "90th_percentile": 0.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 1.3, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1.3, "10th_percentile": 1.3, "90th_percentile": 1.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.46, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.81, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.93, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 2.01, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 2.01, "10th_percentile": 2.01, "90th_percentile": 2.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.85, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.73, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.73 so that total pmt for all claim lines does not exceed 63% 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; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.73 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.98, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.98, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.77, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.77, "10th_percentile": 0.77, "90th_percentile": 0.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.77, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.77, "10th_percentile": 0.77, "90th_percentile": 0.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1.07, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1.07, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "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": "NWR 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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 1.34, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "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": 0.53, "maximum": 2.75, "setting": "outpatient", "gross_charge": 2.75, "discounted_cash": 1.92, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "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": "NWR 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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.73, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.73 so that total pmt for all claim lines does not exceed 63% 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; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.73 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.45, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.45, "10th_percentile": 1.45, "90th_percentile": 1.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC CORE", "standard_charge_dollar": 1.3, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1.3, "10th_percentile": 1.3, "90th_percentile": 1.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 2.01, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 2.01, "10th_percentile": 2.01, "90th_percentile": 2.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.83, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.83, "10th_percentile": 0.83, "90th_percentile": 0.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.46, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.81, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.54, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.93, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.85, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.95, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1.44, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 1.34, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.98, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.98, "10th_percentile": 0.98, "90th_percentile": 0.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.53, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.53, "10th_percentile": 0.53, "90th_percentile": 0.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.98, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 0.98, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1.07, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1.07, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.77, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.77, "10th_percentile": 0.77, "90th_percentile": 0.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.77, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.77, "10th_percentile": 0.77, "90th_percentile": 0.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "AMLODIPINE 1.25 MG ORAL TAB", "drug_information": { "unit": 1.25, "type": "ME" }, "code_information": [ { "code": "RX-4080000210", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "99991-0024-22", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR 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": "NWR BLUE CROSS MEDICARE ADVT", "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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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 CREA", "drug_information": { "unit": 140.0, "type": "GR" }, "code_information": [ { "code": "RX-17997", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00904-5983-48", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.63, "maximum": 24.0, "setting": "outpatient", "gross_charge": 24.0, "discounted_cash": 16.8, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 15.12, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $15.12 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 15.12, "10th_percentile": 15.12, "90th_percentile": 15.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $15.12 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 24.0, "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 $24.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 24.0, "10th_percentile": 24.0, "90th_percentile": 24.0, "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 $24.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 7.42, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.42, "10th_percentile": 7.42, "90th_percentile": 7.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 17.52, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 17.52, "10th_percentile": 17.52, "90th_percentile": 17.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 16.8, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 16.8, "10th_percentile": 16.8, "90th_percentile": 16.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 18.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 18.0, "10th_percentile": 18.0, "90th_percentile": 18.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 4.73, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.73, "10th_percentile": 4.73, "90th_percentile": 4.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 7.28, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 7.28, "10th_percentile": 7.28, "90th_percentile": 7.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 12.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 24.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 24.0, "10th_percentile": 24.0, "90th_percentile": 24.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 12.77, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 12.77, "10th_percentile": 12.77, "90th_percentile": 12.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 11.38, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 11.38, "10th_percentile": 11.38, "90th_percentile": 11.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 15.42, "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": 15.42, "10th_percentile": 15.42, "90th_percentile": 15.42, "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": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 19.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 19.2, "10th_percentile": 19.2, "90th_percentile": 19.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 7.08, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.08, "10th_percentile": 7.08, "90th_percentile": 7.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 12.65, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 4.63, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 4.63, "10th_percentile": 4.63, "90th_percentile": 4.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 8.52, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 8.52, "10th_percentile": 8.52, "90th_percentile": 8.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 12.6, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.6, "10th_percentile": 12.6, "90th_percentile": 12.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 8.26, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 8.26, "10th_percentile": 8.26, "90th_percentile": 8.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 11.69, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.69, "10th_percentile": 11.69, "90th_percentile": 11.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 6.74, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.74, "10th_percentile": 6.74, "90th_percentile": 6.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 6.74, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.74, "10th_percentile": 6.74, "90th_percentile": 6.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 8.56, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.56, "10th_percentile": 8.56, "90th_percentile": 8.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 8.56, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.56, "10th_percentile": 8.56, "90th_percentile": 8.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 9.35, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.35, "10th_percentile": 9.35, "90th_percentile": 9.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 9.35, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.35, "10th_percentile": 9.35, "90th_percentile": 9.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.0, "10th_percentile": 24.0, "90th_percentile": 24.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.0, "10th_percentile": 24.0, "90th_percentile": 24.0, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 24.0, "10th_percentile": 24.0, "90th_percentile": 24.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "AMOXICILLIN 400 MG/5 ML ORAL SUSR", "drug_information": { "unit": 50.0, "type": "ML" }, "code_information": [ { "code": "RX-25246", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00781-6157-52", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.91, "maximum": 20.25, "setting": "outpatient", "gross_charge": 20.25, "discounted_cash": 14.17, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 7.23, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.23, "10th_percentile": 7.23, "90th_percentile": 7.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 7.23, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.23, "10th_percentile": 7.23, "90th_percentile": 7.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5.69, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.69, "10th_percentile": 5.69, "90th_percentile": 5.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5.69, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.69, "10th_percentile": 5.69, "90th_percentile": 5.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 7.89, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.89, "10th_percentile": 7.89, "90th_percentile": 7.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 7.89, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.89, "10th_percentile": 7.89, "90th_percentile": 7.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 6.97, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 6.97, "10th_percentile": 6.97, "90th_percentile": 6.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 7.19, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 7.19, "10th_percentile": 7.19, "90th_percentile": 7.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 10.63, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.63, "10th_percentile": 10.63, "90th_percentile": 10.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 9.86, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 3.91, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 3.91, "10th_percentile": 3.91, "90th_percentile": 3.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 9.6, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 9.6, "10th_percentile": 9.6, "90th_percentile": 9.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 3.99, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.99, "10th_percentile": 3.99, "90th_percentile": 3.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 14.18, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 14.18, "10th_percentile": 14.18, "90th_percentile": 14.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 14.78, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 14.78, "10th_percentile": 14.78, "90th_percentile": 14.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 16.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 16.2, "10th_percentile": 16.2, "90th_percentile": 16.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 6.26, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 10.67, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.67, "10th_percentile": 10.67, "90th_percentile": 10.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 10.77, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 10.77, "10th_percentile": 10.77, "90th_percentile": 10.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 20.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 20.25, "10th_percentile": 20.25, "90th_percentile": 20.25, "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5.97, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.97, "10th_percentile": 5.97, "90th_percentile": 5.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 13.01, "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": 13.01, "10th_percentile": 13.01, "90th_percentile": 13.01, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 15.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 15.19, "10th_percentile": 15.19, "90th_percentile": 15.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 10.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 10.13, "10th_percentile": 10.13, "90th_percentile": 10.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 6.15, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 6.15, "10th_percentile": 6.15, "90th_percentile": 6.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 20.25, "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 $20.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 20.25, "10th_percentile": 20.25, "90th_percentile": 20.25, "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 $20.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 12.76, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $12.76 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 12.76, "10th_percentile": 12.76, "90th_percentile": 12.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $12.76 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20.25, "10th_percentile": 20.25, "90th_percentile": 20.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20.25, "10th_percentile": 20.25, "90th_percentile": 20.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20.25, "10th_percentile": 20.25, "90th_percentile": 20.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; 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": 0.72, "maximum": 3.75, "setting": "outpatient", "gross_charge": 3.75, "discounted_cash": 2.62, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3.75, "10th_percentile": 3.75, "90th_percentile": 3.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3.75, "10th_percentile": 3.75, "90th_percentile": 3.75, "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": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.05, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.05, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.34, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 1.34, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.72, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.72, "10th_percentile": 0.72, "90th_percentile": 0.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1.33, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1.33, "10th_percentile": 1.33, "90th_percentile": 1.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1.97, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.97, "10th_percentile": 1.97, "90th_percentile": 1.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 1.83, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.83, "10th_percentile": 1.83, "90th_percentile": 1.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 1.29, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1.29, "10th_percentile": 1.29, "90th_percentile": 1.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2.81, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 2.81, "10th_percentile": 2.81, "90th_percentile": 2.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.98, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.98, "10th_percentile": 1.98, "90th_percentile": 1.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 1.16, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.16, "10th_percentile": 1.16, "90th_percentile": 1.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.11, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 2.74, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% 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 Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 1.78, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1.78, "10th_percentile": 1.78, "90th_percentile": 1.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 2.0, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% 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; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 2.41, "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": 2.41, "10th_percentile": 2.41, "90th_percentile": 2.41, "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": "NWR BEECHSTREET", "standard_charge_dollar": 3.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 3.0, "10th_percentile": 3.0, "90th_percentile": 3.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 1.14, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2.63, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 2.63, "10th_percentile": 2.63, "90th_percentile": 2.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.88, "10th_percentile": 1.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% 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 OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.74, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 2.36, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2.36 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 2.36, "10th_percentile": 2.36, "90th_percentile": 2.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2.36 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3.75, "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 $3.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "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. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3.75 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3.75, "10th_percentile": 3.75, "90th_percentile": 3.75, "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": "00781-1831-20", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.48, "maximum": 2.5, "setting": "outpatient", "gross_charge": 2.5, "discounted_cash": 1.75, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.89, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.86, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.86, "10th_percentile": 0.86, "90th_percentile": 0.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1.31, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.31, "10th_percentile": 1.31, "90th_percentile": 1.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.48, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% 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; 19.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.49, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.32, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.32, "10th_percentile": 1.32, "90th_percentile": 1.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.76, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.76, "10th_percentile": 0.76, "90th_percentile": 0.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 1.19, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1.19, "10th_percentile": 1.19, "90th_percentile": 1.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.33, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.33, "10th_percentile": 1.33, "90th_percentile": 1.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.74, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.75, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.83, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.83, "10th_percentile": 1.83, "90th_percentile": 1.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.77, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.77, "10th_percentile": 0.77, "90th_percentile": 0.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.58, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.58 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.58 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.7, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": 0.7, "90th_percentile": 0.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.7, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": 0.7, "90th_percentile": 0.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.97, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.97, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "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": "GLOBAL EXCEL [1712]", "plan_name": "NWR 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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 1.22, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "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": 0.48, "maximum": 2.5, "setting": "outpatient", "gross_charge": 2.5, "discounted_cash": 1.75, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR 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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR BLUE CROSS MEDICARE ADVT", "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": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1.31, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.31, "10th_percentile": 1.31, "90th_percentile": 1.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.86, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.86, "10th_percentile": 0.86, "90th_percentile": 0.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.89, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 1.22, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.48, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% 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; 19.3% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.33, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.33, "10th_percentile": 1.33, "90th_percentile": 1.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.32, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.32, "10th_percentile": 1.32, "90th_percentile": 1.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.76, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.76, "10th_percentile": 0.76, "90th_percentile": 0.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.49, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.74, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC CORE", "standard_charge_dollar": 1.19, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1.19, "10th_percentile": 1.19, "90th_percentile": 1.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.77, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.77, "10th_percentile": 0.77, "90th_percentile": 0.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.75, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.83, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.83, "10th_percentile": 1.83, "90th_percentile": 1.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.58, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.58 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.58 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.97, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.97, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.7, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": 0.7, "90th_percentile": 0.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.7, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": 0.7, "90th_percentile": 0.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5 ML ORAL SUSR", "drug_information": { "unit": 75.0, "type": "ML" }, "code_information": [ { "code": "RX-31177", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00781-6139-57", "type": "NDC" } ], "standard_charges": [ { "minimum": 11.68, "maximum": 60.5, "setting": "outpatient", "gross_charge": 60.5, "discounted_cash": 42.35, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 60.5, "10th_percentile": 60.5, "90th_percentile": 60.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 60.5, "10th_percentile": 60.5, "90th_percentile": 60.5, "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": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 16.99, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.99, "10th_percentile": 16.99, "90th_percentile": 16.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 16.99, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.99, "10th_percentile": 16.99, "90th_percentile": 16.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 23.56, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.56, "10th_percentile": 23.56, "90th_percentile": 23.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 23.56, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.56, "10th_percentile": 23.56, "90th_percentile": 23.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 21.59, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.59, "10th_percentile": 21.59, "90th_percentile": 21.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 21.59, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.59, "10th_percentile": 21.59, "90th_percentile": 21.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 11.68, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 11.68, "10th_percentile": 11.68, "90th_percentile": 11.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 45.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 45.38, "10th_percentile": 45.38, "90th_percentile": 45.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 31.88, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.88, "10th_percentile": 31.88, "90th_percentile": 31.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 18.69, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.69, "10th_percentile": 18.69, "90th_percentile": 18.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 17.84, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.84, "10th_percentile": 17.84, "90th_percentile": 17.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 44.17, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 44.17, "10th_percentile": 44.17, "90th_percentile": 44.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 28.68, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 28.68, "10th_percentile": 28.68, "90th_percentile": 28.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 32.19, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 32.19, "10th_percentile": 32.19, "90th_percentile": 32.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 38.86, "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": 38.86, "10th_percentile": 38.86, "90th_percentile": 38.86, "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": "NWR BEECHSTREET", "standard_charge_dollar": 48.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 48.4, "10th_percentile": 48.4, "90th_percentile": 48.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 18.36, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 18.36, "10th_percentile": 18.36, "90th_percentile": 18.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 42.35, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 42.35, "10th_percentile": 42.35, "90th_percentile": 42.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 30.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 30.25, "10th_percentile": 30.25, "90th_percentile": 30.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 60.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 60.5, "10th_percentile": 60.5, "90th_percentile": 60.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 11.92, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.92, "10th_percentile": 11.92, "90th_percentile": 11.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 38.12, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $38.12 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 38.12, "10th_percentile": 38.12, "90th_percentile": 38.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $38.12 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 60.5, "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 $60.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 60.5, "10th_percentile": 60.5, "90th_percentile": 60.5, "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 $60.50 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 60.5, "10th_percentile": 60.5, "90th_percentile": 60.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 29.46, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.46, "10th_percentile": 29.46, "90th_percentile": 29.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 21.48, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 21.48, "10th_percentile": 21.48, "90th_percentile": 21.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 31.76, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.76, "10th_percentile": 31.76, "90th_percentile": 31.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 20.81, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 20.81, "10th_percentile": 20.81, "90th_percentile": 20.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" } ] } ] }, { "description": "AMPHOTERICIN B LIPOSOME 50 MG IV SUSR", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-21900", "type": "CDM" }, { "code": "J0289", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "62756-0233-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 96.64, "maximum": 500.75, "setting": "outpatient", "gross_charge": 500.75, "discounted_cash": 350.52, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 500.75, "10th_percentile": 500.75, "90th_percentile": 500.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 500.75, "10th_percentile": 500.75, "90th_percentile": 500.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $500.75 @ 12.5% = $62.59 due to $0.00 Claim Price", "median_amount": 62.59, "10th_percentile": 62.59, "90th_percentile": 62.59, "count": "0", "methodology": "other", "additional_payer_notes": "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: $500.75 @ 12.5% = $62.59 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 239.36, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 239.36, "10th_percentile": 239.36, "90th_percentile": 239.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 239.36, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 239.36, "10th_percentile": 239.36, "90th_percentile": 239.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 239.36, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 239.36, "10th_percentile": 239.36, "90th_percentile": 239.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 178.67, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 178.67, "10th_percentile": 178.67, "90th_percentile": 178.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 178.67, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 178.67, "10th_percentile": 178.67, "90th_percentile": 178.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 169.75, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 169.75, "10th_percentile": 169.75, "90th_percentile": 169.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 169.75, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 169.75, "10th_percentile": 169.75, "90th_percentile": 169.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 375.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 375.56, "10th_percentile": 375.56, "90th_percentile": 375.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 365.55, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 365.55, "10th_percentile": 365.55, "90th_percentile": 365.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 172.26, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 172.26, "10th_percentile": 172.26, "90th_percentile": 172.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 250.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 250.38, "10th_percentile": 250.38, "90th_percentile": 250.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 400.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 400.6, "10th_percentile": 400.6, "90th_percentile": 400.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 350.53, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 350.53, "10th_percentile": 350.53, "90th_percentile": 350.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 151.98, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 151.98, "10th_percentile": 151.98, "90th_percentile": 151.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 266.4, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 266.4, "10th_percentile": 266.4, "90th_percentile": 266.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 262.89, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 262.89, "10th_percentile": 262.89, "90th_percentile": 262.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 500.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 500.75, "10th_percentile": 500.75, "90th_percentile": 500.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 96.64, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 96.64, "10th_percentile": 96.64, "90th_percentile": 96.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 177.77, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 177.77, "10th_percentile": 177.77, "90th_percentile": 177.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 500.75, "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 $500.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 500.75, "10th_percentile": 500.75, "90th_percentile": 500.75, "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 $500.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 315.47, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $315.47 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 315.47, "10th_percentile": 315.47, "90th_percentile": 315.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $315.47 so that total pmt for all claim lines does not exceed 63% of claim billed amount." } ] } ] }, { "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": 8.35, "maximum": 43.25, "setting": "outpatient", "gross_charge": 43.25, "discounted_cash": 30.27, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 43.25, "10th_percentile": 43.25, "90th_percentile": 43.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 43.25, "10th_percentile": 43.25, "90th_percentile": 43.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $43.25 @ 12.5% = $5.41 due to $0.00 Claim Price", "median_amount": 5.41, "10th_percentile": 5.41, "90th_percentile": 5.41, "count": "0", "methodology": "other", "additional_payer_notes": "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: $43.25 @ 12.5% = $5.41 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 43.25, "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 $43.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 43.25, "10th_percentile": 43.25, "90th_percentile": 43.25, "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 $43.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 27.25, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $27.25 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 27.25, "10th_percentile": 27.25, "90th_percentile": 27.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $27.25 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 8.35, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 8.35, "10th_percentile": 8.35, "90th_percentile": 8.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 13.13, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 13.13, "10th_percentile": 13.13, "90th_percentile": 13.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 43.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 43.25, "10th_percentile": 43.25, "90th_percentile": 43.25, "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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 30.28, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 30.28, "10th_percentile": 30.28, "90th_percentile": 30.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 22.71, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.71, "10th_percentile": 22.71, "90th_percentile": 22.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 14.88, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 14.88, "10th_percentile": 14.88, "90th_percentile": 14.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 21.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 21.63, "10th_percentile": 21.63, "90th_percentile": 21.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 32.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 32.44, "10th_percentile": 32.44, "90th_percentile": 32.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 31.57, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 31.57, "10th_percentile": 31.57, "90th_percentile": 31.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 23.01, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 23.01, "10th_percentile": 23.01, "90th_percentile": 23.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 34.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 34.6, "10th_percentile": 34.6, "90th_percentile": 34.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 15.35, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 15.35, "10th_percentile": 15.35, "90th_percentile": 15.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 14.66, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.66, "10th_percentile": 14.66, "90th_percentile": 14.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 14.66, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.66, "10th_percentile": 14.66, "90th_percentile": 14.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 15.43, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.43, "10th_percentile": 15.43, "90th_percentile": 15.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 15.43, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.43, "10th_percentile": 15.43, "90th_percentile": 15.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 20.67, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.67, "10th_percentile": 20.67, "90th_percentile": 20.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 20.67, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.67, "10th_percentile": 20.67, "90th_percentile": 20.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 20.67, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.67, "10th_percentile": 20.67, "90th_percentile": 20.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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 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": "67850-0022-00", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.87, "maximum": 25.25, "setting": "outpatient", "gross_charge": 25.25, "discounted_cash": 17.67, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 25.25, "10th_percentile": 25.25, "90th_percentile": 25.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 25.25, "10th_percentile": 25.25, "90th_percentile": 25.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $25.25 @ 12.5% = $3.16 due to $0.00 Claim Price", "median_amount": 3.16, "10th_percentile": 3.16, "90th_percentile": 3.16, "count": "0", "methodology": "other", "additional_payer_notes": "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: $25.25 @ 12.5% = $3.16 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 25.25, "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 $25.25 so that total pmt for all claim lines does not exceed 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. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $25.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 15.91, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $15.91 so that total pmt for all claim lines does not exceed 63% 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; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $15.91 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 4.87, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 4.87, "10th_percentile": 4.87, "90th_percentile": 4.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 7.66, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 7.66, "10th_percentile": 7.66, "90th_percentile": 7.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 25.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 25.25, "10th_percentile": 25.25, "90th_percentile": 25.25, "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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 17.68, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 17.68, "10th_percentile": 17.68, "90th_percentile": 17.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 13.26, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.26, "10th_percentile": 13.26, "90th_percentile": 13.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 8.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 8.69, "10th_percentile": 8.69, "90th_percentile": 8.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 12.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 12.63, "10th_percentile": 12.63, "90th_percentile": 12.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 18.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 18.94, "10th_percentile": 18.94, "90th_percentile": 18.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 18.43, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 18.43, "10th_percentile": 18.43, "90th_percentile": 18.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 13.43, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 13.43, "10th_percentile": 13.43, "90th_percentile": 13.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 20.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 8.96, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 8.96, "10th_percentile": 8.96, "90th_percentile": 8.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 8.56, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.56, "10th_percentile": 8.56, "90th_percentile": 8.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 8.56, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.56, "10th_percentile": 8.56, "90th_percentile": 8.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 9.01, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.01, "10th_percentile": 9.01, "90th_percentile": 9.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 9.01, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.01, "10th_percentile": 9.01, "90th_percentile": 9.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 12.07, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.07, "10th_percentile": 12.07, "90th_percentile": 12.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 12.07, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.07, "10th_percentile": 12.07, "90th_percentile": 12.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 12.07, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.07, "10th_percentile": 12.07, "90th_percentile": 12.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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 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": 4.87, "maximum": 25.25, "setting": "outpatient", "gross_charge": 25.25, "discounted_cash": 17.67, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $25.25 @ 12.5% = $3.16 due to $0.00 Claim Price", "median_amount": 3.16, "10th_percentile": 3.16, "90th_percentile": 3.16, "count": "0", "methodology": "other", "additional_payer_notes": "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: $25.25 @ 12.5% = $3.16 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 25.25, "10th_percentile": 25.25, "90th_percentile": 25.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 25.25, "10th_percentile": 25.25, "90th_percentile": 25.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 15.91, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $15.91 so that total pmt for all claim lines does not exceed 63% 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; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $15.91 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 25.25, "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 $25.25 so that total pmt for all claim lines does not exceed 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. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $25.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 13.43, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 13.43, "10th_percentile": 13.43, "90th_percentile": 13.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 25.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 25.25, "10th_percentile": 25.25, "90th_percentile": 25.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 7.66, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 7.66, "10th_percentile": 7.66, "90th_percentile": 7.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 18.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 18.94, "10th_percentile": 18.94, "90th_percentile": 18.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 20.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 20.2, "10th_percentile": 20.2, "90th_percentile": 20.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 12.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 12.63, "10th_percentile": 12.63, "90th_percentile": 12.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 13.26, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.26, "10th_percentile": 13.26, "90th_percentile": 13.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 4.87, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 4.87, "10th_percentile": 4.87, "90th_percentile": 4.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 8.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 8.69, "10th_percentile": 8.69, "90th_percentile": 8.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 17.68, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 17.68, "10th_percentile": 17.68, "90th_percentile": 17.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 8.96, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 8.96, "10th_percentile": 8.96, "90th_percentile": 8.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 18.43, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 18.43, "10th_percentile": 18.43, "90th_percentile": 18.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 8.56, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.56, "10th_percentile": 8.56, "90th_percentile": 8.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 8.56, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.56, "10th_percentile": 8.56, "90th_percentile": 8.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 9.01, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.01, "10th_percentile": 9.01, "90th_percentile": 9.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 9.01, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.01, "10th_percentile": 9.01, "90th_percentile": 9.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 12.07, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.07, "10th_percentile": 12.07, "90th_percentile": 12.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 12.07, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.07, "10th_percentile": 12.07, "90th_percentile": 12.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 12.07, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.07, "10th_percentile": 12.07, "90th_percentile": 12.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": 1.11, "maximum": 5.75, "setting": "outpatient", "gross_charge": 5.75, "discounted_cash": 4.02, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $5.75 @ 12.5% = $0.72 due to $0.00 Claim Price", "median_amount": 0.72, "10th_percentile": 0.72, "90th_percentile": 0.72, "count": "0", "methodology": "other", "additional_payer_notes": "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: $5.75 @ 12.5% = $0.72 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 3.62, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $3.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 3.62, "10th_percentile": 3.62, "90th_percentile": 3.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $3.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 3.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 3.06, "10th_percentile": 3.06, "90th_percentile": 3.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 1.75, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% 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; 30.35% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 4.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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": "HEALTHLINK [125]", "plan_name": "NWR 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": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 3.02, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.02, "10th_percentile": 3.02, "90th_percentile": 3.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 1.11, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1.11, "10th_percentile": 1.11, "90th_percentile": 1.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 1.98, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1.98, "10th_percentile": 1.98, "90th_percentile": 1.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 4.03, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 2.04, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 2.04, "10th_percentile": 2.04, "90th_percentile": 2.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 4.2, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 4.2, "10th_percentile": 4.2, "90th_percentile": 4.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1.95, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.95, "10th_percentile": 1.95, "90th_percentile": 1.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1.95, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.95, "10th_percentile": 1.95, "90th_percentile": 1.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 2.05, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 2.05, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.75, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.75, "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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.75, "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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2.75, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.75, "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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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 1.5 G INJ SOLR", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-27282", "type": "CDM" }, { "code": "J0295", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "55150-0116-20", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.83, "maximum": 9.5, "setting": "outpatient", "gross_charge": 9.5, "discounted_cash": 6.65, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.5, "10th_percentile": 9.5, "90th_percentile": 9.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.5, "10th_percentile": 9.5, "90th_percentile": 9.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $9.50 @ 12.5% = $1.19 due to $0.00 Claim Price", "median_amount": 1.19, "10th_percentile": 1.19, "90th_percentile": 1.19, "count": "0", "methodology": "other", "additional_payer_notes": "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: $9.50 @ 12.5% = $1.19 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4.54, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4.54, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4.54, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 3.39, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.39, "10th_percentile": 3.39, "90th_percentile": 3.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 3.39, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.39, "10th_percentile": 3.39, "90th_percentile": 3.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 3.22, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.22, "10th_percentile": 3.22, "90th_percentile": 3.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 3.22, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.22, "10th_percentile": 3.22, "90th_percentile": 3.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 7.13, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 7.13, "10th_percentile": 7.13, "90th_percentile": 7.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 6.94, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 6.94, "10th_percentile": 6.94, "90th_percentile": 6.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 3.27, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 3.27, "10th_percentile": 3.27, "90th_percentile": 3.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 4.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 7.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 7.6, "10th_percentile": 7.6, "90th_percentile": 7.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 6.65, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 6.65, "10th_percentile": 6.65, "90th_percentile": 6.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 2.88, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% 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; 30.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 5.05, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 5.05, "10th_percentile": 5.05, "90th_percentile": 5.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 4.99, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.5, "10th_percentile": 9.5, "90th_percentile": 9.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 1.83, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1.83, "10th_percentile": 1.83, "90th_percentile": 1.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 3.37, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 3.37, "10th_percentile": 3.37, "90th_percentile": 3.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 9.5, "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 $9.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 9.5, "10th_percentile": 9.5, "90th_percentile": 9.5, "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 $9.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 5.99, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $5.99 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 5.99, "10th_percentile": 5.99, "90th_percentile": 5.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $5.99 so that total pmt for all claim lines does not exceed 63% 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": "00641-6117-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.81, "maximum": 19.75, "setting": "outpatient", "gross_charge": 19.75, "discounted_cash": 13.82, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 19.75, "10th_percentile": 19.75, "90th_percentile": 19.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 19.75, "10th_percentile": 19.75, "90th_percentile": 19.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $19.75 @ 12.5% = $2.47 due to $0.00 Claim Price", "median_amount": 2.47, "10th_percentile": 2.47, "90th_percentile": 2.47, "count": "0", "methodology": "other", "additional_payer_notes": "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: $19.75 @ 12.5% = $2.47 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 9.44, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.44, "10th_percentile": 9.44, "90th_percentile": 9.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 9.44, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.44, "10th_percentile": 9.44, "90th_percentile": 9.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 9.44, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.44, "10th_percentile": 9.44, "90th_percentile": 9.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 7.05, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.05, "10th_percentile": 7.05, "90th_percentile": 7.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 7.05, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.05, "10th_percentile": 7.05, "90th_percentile": 7.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 6.7, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 6.7, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 14.81, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 14.81, "10th_percentile": 14.81, "90th_percentile": 14.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 14.42, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 14.42, "10th_percentile": 14.42, "90th_percentile": 14.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 6.79, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 6.79, "10th_percentile": 6.79, "90th_percentile": 6.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 9.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 9.88, "10th_percentile": 9.88, "90th_percentile": 9.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 15.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 15.8, "10th_percentile": 15.8, "90th_percentile": 15.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 13.83, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 13.83, "10th_percentile": 13.83, "90th_percentile": 13.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 5.99, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 5.99, "10th_percentile": 5.99, "90th_percentile": 5.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 10.51, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 10.51, "10th_percentile": 10.51, "90th_percentile": 10.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 10.37, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.37, "10th_percentile": 10.37, "90th_percentile": 10.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 19.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 19.75, "10th_percentile": 19.75, "90th_percentile": 19.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 3.81, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 3.81, "10th_percentile": 3.81, "90th_percentile": 3.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 7.01, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 7.01, "10th_percentile": 7.01, "90th_percentile": 7.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 19.75, "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 $19.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 19.75, "10th_percentile": 19.75, "90th_percentile": 19.75, "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 $19.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 12.44, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $12.44 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 12.44, "10th_percentile": 12.44, "90th_percentile": 12.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $12.44 so that total pmt for all claim lines does not exceed 63% 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": 3.81, "maximum": 19.75, "setting": "outpatient", "gross_charge": 19.75, "discounted_cash": 13.82, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 19.75, "10th_percentile": 19.75, "90th_percentile": 19.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 19.75, "10th_percentile": 19.75, "90th_percentile": 19.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $19.75 @ 12.5% = $2.47 due to $0.00 Claim Price", "median_amount": 2.47, "10th_percentile": 2.47, "90th_percentile": 2.47, "count": "0", "methodology": "other", "additional_payer_notes": "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: $19.75 @ 12.5% = $2.47 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 9.44, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.44, "10th_percentile": 9.44, "90th_percentile": 9.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 9.44, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.44, "10th_percentile": 9.44, "90th_percentile": 9.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 9.44, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.44, "10th_percentile": 9.44, "90th_percentile": 9.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 7.05, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.05, "10th_percentile": 7.05, "90th_percentile": 7.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 7.05, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.05, "10th_percentile": 7.05, "90th_percentile": 7.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 6.7, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 6.7, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 14.81, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 14.81, "10th_percentile": 14.81, "90th_percentile": 14.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 14.42, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 14.42, "10th_percentile": 14.42, "90th_percentile": 14.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 6.79, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 6.79, "10th_percentile": 6.79, "90th_percentile": 6.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 9.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 9.88, "10th_percentile": 9.88, "90th_percentile": 9.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 15.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 15.8, "10th_percentile": 15.8, "90th_percentile": 15.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 13.83, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 13.83, "10th_percentile": 13.83, "90th_percentile": 13.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 5.99, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 5.99, "10th_percentile": 5.99, "90th_percentile": 5.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 10.51, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 10.51, "10th_percentile": 10.51, "90th_percentile": 10.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 10.37, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.37, "10th_percentile": 10.37, "90th_percentile": 10.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 19.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 19.75, "10th_percentile": 19.75, "90th_percentile": 19.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 3.81, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 3.81, "10th_percentile": 3.81, "90th_percentile": 3.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 7.01, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 7.01, "10th_percentile": 7.01, "90th_percentile": 7.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 19.75, "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 $19.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 19.75, "10th_percentile": 19.75, "90th_percentile": 19.75, "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 $19.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 12.44, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $12.44 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 12.44, "10th_percentile": 12.44, "90th_percentile": 12.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $12.44 so that total pmt for all claim lines does not exceed 63% 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": "55150-0117-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.52, "maximum": 18.25, "setting": "outpatient", "gross_charge": 18.25, "discounted_cash": 12.77, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 18.25, "10th_percentile": 18.25, "90th_percentile": 18.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 18.25, "10th_percentile": 18.25, "90th_percentile": 18.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $18.25 @ 12.5% = $2.28 due to $0.00 Claim Price", "median_amount": 2.28, "10th_percentile": 2.28, "90th_percentile": 2.28, "count": "0", "methodology": "other", "additional_payer_notes": "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: $18.25 @ 12.5% = $2.28 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 8.72, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 8.72, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 8.72, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 6.51, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.51, "10th_percentile": 6.51, "90th_percentile": 6.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 6.51, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.51, "10th_percentile": 6.51, "90th_percentile": 6.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 6.19, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.19, "10th_percentile": 6.19, "90th_percentile": 6.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 6.19, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.19, "10th_percentile": 6.19, "90th_percentile": 6.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 13.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 13.69, "10th_percentile": 13.69, "90th_percentile": 13.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 13.32, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 13.32, "10th_percentile": 13.32, "90th_percentile": 13.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 6.28, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 6.28, "10th_percentile": 6.28, "90th_percentile": 6.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 9.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 9.13, "10th_percentile": 9.13, "90th_percentile": 9.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 14.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 14.6, "10th_percentile": 14.6, "90th_percentile": 14.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 12.78, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 12.78, "10th_percentile": 12.78, "90th_percentile": 12.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 5.54, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% 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; 30.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 9.71, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 9.71, "10th_percentile": 9.71, "90th_percentile": 9.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 9.58, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.58, "10th_percentile": 9.58, "90th_percentile": 9.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 18.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 18.25, "10th_percentile": 18.25, "90th_percentile": 18.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 3.52, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 3.52, "10th_percentile": 3.52, "90th_percentile": 3.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 6.48, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 6.48, "10th_percentile": 6.48, "90th_percentile": 6.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 18.25, "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 $18.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 18.25, "10th_percentile": 18.25, "90th_percentile": 18.25, "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 $18.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 11.5, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $11.50 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 11.5, "10th_percentile": 11.5, "90th_percentile": 11.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $11.50 so that total pmt for all claim lines does not exceed 63% 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": 24.79, "maximum": 128.43, "setting": "outpatient", "gross_charge": 128.43, "discounted_cash": 89.9, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 39.68, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.4, "10th_percentile": 45.4, "90th_percentile": 45.4, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 67.68, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 51.76, "10th_percentile": 51.76, "90th_percentile": 51.76, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 25.3, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.92, "10th_percentile": 10.92, "90th_percentile": 10.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 80.91, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $80.91 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 80.91, "10th_percentile": 80.91, "90th_percentile": 80.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $80.91 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 38.98, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 38.98, "10th_percentile": 38.98, "90th_percentile": 38.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 128.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 128.43, "10th_percentile": 128.43, "90th_percentile": 128.43, "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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 89.9, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 89.9, "10th_percentile": 89.9, "90th_percentile": 89.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 60.88, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 60.88, "10th_percentile": 60.88, "90th_percentile": 60.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 64.22, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 64.22, "10th_percentile": 64.22, "90th_percentile": 64.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 96.32, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 96.32, "10th_percentile": 96.32, "90th_percentile": 96.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 93.75, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 93.75, "10th_percentile": 93.75, "90th_percentile": 93.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 82.49, "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": 82.49, "10th_percentile": 82.49, "90th_percentile": 82.49, "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": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $128.43 @ 12.5% = $16.05 due to $0.00 Claim Price", "median_amount": 16.05, "10th_percentile": 16.05, "90th_percentile": 16.05, "count": "0", "methodology": "other", "additional_payer_notes": "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: $128.43 @ 12.5% = $16.05 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 128.43, "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 $128.43 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 128.43, "10th_percentile": 128.43, "90th_percentile": 128.43, "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 $128.43 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 68.32, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 68.32, "10th_percentile": 68.32, "90th_percentile": 68.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 102.74, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 102.74, "10th_percentile": 102.74, "90th_percentile": 102.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 45.59, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 45.59, "10th_percentile": 45.59, "90th_percentile": 45.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 44.18, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 44.18, "10th_percentile": 44.18, "90th_percentile": 44.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 24.79, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 24.79, "10th_percentile": 24.79, "90th_percentile": 24.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 67.43, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.43, "10th_percentile": 67.43, "90th_percentile": 67.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 62.55, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.55, "10th_percentile": 62.55, "90th_percentile": 62.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 43.54, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.54, "10th_percentile": 43.54, "90th_percentile": 43.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 43.54, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.54, "10th_percentile": 43.54, "90th_percentile": 43.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 45.82, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.82, "10th_percentile": 45.82, "90th_percentile": 45.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 45.82, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.82, "10th_percentile": 45.82, "90th_percentile": 45.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 61.39, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.39, "10th_percentile": 61.39, "90th_percentile": 61.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 61.39, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.39, "10th_percentile": 61.39, "90th_percentile": 61.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 61.39, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.39, "10th_percentile": 61.39, "90th_percentile": 61.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 128.43, "10th_percentile": 128.43, "90th_percentile": 128.43, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 128.43, "10th_percentile": 128.43, "90th_percentile": 128.43, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "AMPLATZER 4 5X10.5MM PLUG VASC OCCL", "code_information": [ { "code": "SUP-143419", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 787.03, "maximum": 4077.88, "setting": "outpatient", "gross_charge": 4077.88, "discounted_cash": 2854.52, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $4,077.88 @ 12.5% = $509.74 due to $0.00 Claim Price", "median_amount": 509.74, "10th_percentile": 509.74, "90th_percentile": 509.74, "count": "0", "methodology": "other", "additional_payer_notes": "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: $4,077.88 @ 12.5% = $509.74 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4077.88, "10th_percentile": 4077.88, "90th_percentile": 4077.88, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4077.88, "10th_percentile": 4077.88, "90th_percentile": 4077.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 1402.79, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1402.79, "10th_percentile": 1402.79, "90th_percentile": 1402.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 2038.94, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 2038.94, "10th_percentile": 2038.94, "90th_percentile": 2038.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 803.34, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 803.34, "10th_percentile": 803.34, "90th_percentile": 803.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 2976.85, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 2976.85, "10th_percentile": 2976.85, "90th_percentile": 2976.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 1237.64, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 1237.64, "10th_percentile": 1237.64, "90th_percentile": 1237.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 1932.92, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1932.92, "10th_percentile": 1932.92, "90th_percentile": 1932.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 3058.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 3058.41, "10th_percentile": 3058.41, "90th_percentile": 3058.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1447.65, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1447.65, "10th_percentile": 1447.65, "90th_percentile": 1447.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 2619.22, "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": 2619.22, "10th_percentile": 2619.22, "90th_percentile": 2619.22, "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": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 3262.3, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 3262.3, "10th_percentile": 3262.3, "90th_percentile": 3262.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 2169.43, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 2169.43, "10th_percentile": 2169.43, "90th_percentile": 2169.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 1260.06, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1260.06, "10th_percentile": 1260.06, "90th_percentile": 1260.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2854.52, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 2854.52, "10th_percentile": 2854.52, "90th_percentile": 2854.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 4077.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4077.88, "10th_percentile": 4077.88, "90th_percentile": 4077.88, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4077.88, "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 $4,077.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4077.88, "10th_percentile": 4077.88, "90th_percentile": 4077.88, "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 $4,077.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 2569.06, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,569.06 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 2569.06, "10th_percentile": 2569.06, "90th_percentile": 2569.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,569.06 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 2149.04, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.47, "10th_percentile": 45.47, "90th_percentile": 45.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 787.03, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 8.1, "10th_percentile": 8.1, "90th_percentile": 8.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1382.4, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1382.4, "10th_percentile": 1382.4, "90th_percentile": 1382.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1382.4, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1382.4, "10th_percentile": 1382.4, "90th_percentile": 1382.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 1454.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1454.99, "10th_percentile": 1454.99, "90th_percentile": 1454.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1454.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1454.99, "10th_percentile": 1454.99, "90th_percentile": 1454.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1190.74, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1190.74, "10th_percentile": 1190.74, "90th_percentile": 1190.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 1190.74, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1190.74, "10th_percentile": 1190.74, "90th_percentile": 1190.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1949.23, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1949.23, "10th_percentile": 1949.23, "90th_percentile": 1949.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1949.23, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1949.23, "10th_percentile": 1949.23, "90th_percentile": 1949.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1949.23, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1949.23, "10th_percentile": 1949.23, "90th_percentile": 1949.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "AMPLATZER 4 PLUG 6MM VASCULAR", "code_information": [ { "code": "SUP-143420", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 787.03, "maximum": 4077.88, "setting": "outpatient", "gross_charge": 4077.88, "discounted_cash": 2854.52, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $4,077.88 @ 12.5% = $509.74 due to $0.00 Claim Price", "median_amount": 509.74, "10th_percentile": 509.74, "90th_percentile": 509.74, "count": "0", "methodology": "other", "additional_payer_notes": "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: $4,077.88 @ 12.5% = $509.74 due to $0.00 Claim Price" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 2149.04, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.47, "10th_percentile": 45.47, "90th_percentile": 45.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 2569.06, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,569.06 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 2569.06, "10th_percentile": 2569.06, "90th_percentile": 2569.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,569.06 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4077.88, "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 $4,077.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4077.88, "10th_percentile": 4077.88, "90th_percentile": 4077.88, "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 $4,077.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 1932.92, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1932.92, "10th_percentile": 1932.92, "90th_percentile": 1932.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2854.52, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 2854.52, "10th_percentile": 2854.52, "90th_percentile": 2854.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 2619.22, "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": 2619.22, "10th_percentile": 2619.22, "90th_percentile": 2619.22, "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": "NWR HFN PPO", "standard_charge_dollar": 2976.85, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 2976.85, "10th_percentile": 2976.85, "90th_percentile": 2976.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 3058.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 3058.41, "10th_percentile": 3058.41, "90th_percentile": 3058.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 1260.06, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1260.06, "10th_percentile": 1260.06, "90th_percentile": 1260.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 1237.64, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 1237.64, "10th_percentile": 1237.64, "90th_percentile": 1237.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 2038.94, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 2038.94, "10th_percentile": 2038.94, "90th_percentile": 2038.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 803.34, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 803.34, "10th_percentile": 803.34, "90th_percentile": 803.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 2169.43, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 2169.43, "10th_percentile": 2169.43, "90th_percentile": 2169.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 4077.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4077.88, "10th_percentile": 4077.88, "90th_percentile": 4077.88, "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": "NWR BCBS PPO", "standard_charge_dollar": 1382.4, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1382.4, "10th_percentile": 1382.4, "90th_percentile": 1382.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1454.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1454.99, "10th_percentile": 1454.99, "90th_percentile": 1454.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1949.23, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1949.23, "10th_percentile": 1949.23, "90th_percentile": 1949.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4077.88, "10th_percentile": 4077.88, "90th_percentile": 4077.88, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4077.88, "10th_percentile": 4077.88, "90th_percentile": 4077.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 1402.79, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1402.79, "10th_percentile": 1402.79, "90th_percentile": 1402.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1447.65, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1447.65, "10th_percentile": 1447.65, "90th_percentile": 1447.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 3262.3, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 3262.3, "10th_percentile": 3262.3, "90th_percentile": 3262.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 787.03, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 8.1, "10th_percentile": 8.1, "90th_percentile": 8.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1382.4, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1382.4, "10th_percentile": 1382.4, "90th_percentile": 1382.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 1454.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1454.99, "10th_percentile": 1454.99, "90th_percentile": 1454.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1190.74, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1190.74, "10th_percentile": 1190.74, "90th_percentile": 1190.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 1190.74, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1190.74, "10th_percentile": 1190.74, "90th_percentile": 1190.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1949.23, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1949.23, "10th_percentile": 1949.23, "90th_percentile": 1949.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1949.23, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1949.23, "10th_percentile": 1949.23, "90th_percentile": 1949.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "AMPLATZER PLUG VASC OCCL 6X7MM NIT", "code_information": [ { "code": "SUP-112018", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 603.11, "maximum": 3124.94, "setting": "outpatient", "gross_charge": 3124.94, "discounted_cash": 2187.46, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $3,124.94 @ 12.5% = $390.62 due to $0.00 Claim Price", "median_amount": 390.62, "10th_percentile": 390.62, "90th_percentile": 390.62, "count": "0", "methodology": "other", "additional_payer_notes": "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: $3,124.94 @ 12.5% = $390.62 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3124.94, "10th_percentile": 3124.94, "90th_percentile": 3124.94, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3124.94, "10th_percentile": 3124.94, "90th_percentile": 3124.94, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 1074.98, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1074.98, "10th_percentile": 1074.98, "90th_percentile": 1074.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1562.47, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1562.47, "10th_percentile": 1562.47, "90th_percentile": 1562.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 615.61, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 615.61, "10th_percentile": 615.61, "90th_percentile": 615.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 2281.21, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 2281.21, "10th_percentile": 2281.21, "90th_percentile": 2281.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 948.42, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 948.42, "10th_percentile": 948.42, "90th_percentile": 948.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 1481.22, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1481.22, "10th_percentile": 1481.22, "90th_percentile": 1481.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2343.71, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 2343.71, "10th_percentile": 2343.71, "90th_percentile": 2343.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1109.35, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1109.35, "10th_percentile": 1109.35, "90th_percentile": 1109.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 2007.15, "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": 2007.15, "10th_percentile": 2007.15, "90th_percentile": 2007.15, "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": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 2499.95, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2499.95, "10th_percentile": 2499.95, "90th_percentile": 2499.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1662.47, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1662.47, "10th_percentile": 1662.47, "90th_percentile": 1662.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 965.61, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 965.61, "10th_percentile": 965.61, "90th_percentile": 965.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2187.46, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 2187.46, "10th_percentile": 2187.46, "90th_percentile": 2187.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 3124.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3124.94, "10th_percentile": 3124.94, "90th_percentile": 3124.94, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3124.94, "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 $3,124.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3124.94, "10th_percentile": 3124.94, "90th_percentile": 3124.94, "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 $3,124.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1968.71, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,968.71 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1968.71, "10th_percentile": 1968.71, "90th_percentile": 1968.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,968.71 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1646.84, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.47, "10th_percentile": 45.47, "90th_percentile": 45.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 603.11, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 8.1, "10th_percentile": 8.1, "90th_percentile": 8.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1059.35, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1059.35, "10th_percentile": 1059.35, "90th_percentile": 1059.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1059.35, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1059.35, "10th_percentile": 1059.35, "90th_percentile": 1059.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 1114.98, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1114.98, "10th_percentile": 1114.98, "90th_percentile": 1114.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1114.98, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1114.98, "10th_percentile": 1114.98, "90th_percentile": 1114.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 912.48, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 912.48, "10th_percentile": 912.48, "90th_percentile": 912.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 912.48, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 912.48, "10th_percentile": 912.48, "90th_percentile": 912.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1493.72, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1493.72, "10th_percentile": 1493.72, "90th_percentile": 1493.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1493.72, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1493.72, "10th_percentile": 1493.72, "90th_percentile": 1493.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1493.72, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1493.72, "10th_percentile": 1493.72, "90th_percentile": 1493.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANASTROZOLE 1 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-16205", "type": "CDM" }, { "code": "J9999", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "50268-0075-15", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.63, "maximum": 3.25, "setting": "outpatient", "gross_charge": 3.25, "discounted_cash": 2.27, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "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": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $3.25 @ 12.5% = $0.41 due to $0.00 Claim Price", "median_amount": 3.25, "10th_percentile": 3.25, "90th_percentile": 3.25, "count": "0", "methodology": "other", "additional_payer_notes": "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: $3.25 @ 12.5% = $0.41 due to $0.00 Claim Price" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 1.58, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.58, "10th_percentile": 1.58, "90th_percentile": 1.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 1.12, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1.12, "10th_percentile": 1.12, "90th_percentile": 1.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1.71, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1.15, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1.15, "10th_percentile": 1.15, "90th_percentile": 1.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.63, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.63, "10th_percentile": 0.63, "90th_percentile": 0.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.16, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.16, "10th_percentile": 1.16, "90th_percentile": 1.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1.1, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.55, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.55, "10th_percentile": 1.55, "90th_percentile": 1.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.55, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.55, "10th_percentile": 1.55, "90th_percentile": 1.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.55, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.55, "10th_percentile": 1.55, "90th_percentile": 1.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.16, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.16, "10th_percentile": 1.16, "90th_percentile": 1.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1.1, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.73, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.73, "10th_percentile": 1.73, "90th_percentile": 1.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2.28, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 2.37, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% 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; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.99, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.99, "10th_percentile": 0.99, "90th_percentile": 0.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 2.05, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2.05 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2.05 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "NWR UHC CORE", "standard_charge_dollar": 1.54, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1.54, "10th_percentile": 1.54, "90th_percentile": 1.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.71, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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" } ] } ] }, { "description": "ANCHOR HEALIX 5.5MM 222233", "code_information": [ { "code": "SUP-304226", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 281.52, "maximum": 1458.63, "setting": "outpatient", "gross_charge": 1458.63, "discounted_cash": 1021.04, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 768.7, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 450.72, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,458.63 @ 12.5% = $182.33 due to $0.00 Claim Price", "median_amount": 182.33, "10th_percentile": 182.33, "90th_percentile": 182.33, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,458.63 @ 12.5% = $182.33 due to $0.00 Claim Price" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1021.04, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1021.04, "10th_percentile": 1021.04, "90th_percentile": 1021.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 729.32, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 729.32, "10th_percentile": 729.32, "90th_percentile": 729.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1093.97, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1093.97, "10th_percentile": 1093.97, "90th_percentile": 1093.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1064.8, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1064.8, "10th_percentile": 1064.8, "90th_percentile": 1064.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 918.94, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $918.94 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 918.94, "10th_percentile": 918.94, "90th_percentile": 918.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $918.94 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 442.69, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 442.69, "10th_percentile": 442.69, "90th_percentile": 442.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 691.39, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 691.39, "10th_percentile": 691.39, "90th_percentile": 691.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 936.88, "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": 936.88, "10th_percentile": 936.88, "90th_percentile": 936.88, "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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1458.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1458.63, "10th_percentile": 1458.63, "90th_percentile": 1458.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 281.52, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1458.63, "10th_percentile": 1458.63, "90th_percentile": 1458.63, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1458.63, "10th_percentile": 1458.63, "90th_percentile": 1458.63, "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": "NWR BCBS PPO", "standard_charge_dollar": 494.48, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 494.48, "10th_percentile": 494.48, "90th_percentile": 494.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 494.48, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 494.48, "10th_percentile": 494.48, "90th_percentile": 494.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 425.92, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 425.92, "10th_percentile": 425.92, "90th_percentile": 425.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 425.92, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 425.92, "10th_percentile": 425.92, "90th_percentile": 425.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 520.44, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 520.44, "10th_percentile": 520.44, "90th_percentile": 520.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 520.44, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 520.44, "10th_percentile": 520.44, "90th_percentile": 520.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 517.81, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 517.81, "10th_percentile": 517.81, "90th_percentile": 517.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 775.99, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 775.99, "10th_percentile": 775.99, "90th_percentile": 775.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 501.77, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 501.77, "10th_percentile": 501.77, "90th_percentile": 501.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1458.63, "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 $1,458.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1458.63, "10th_percentile": 1458.63, "90th_percentile": 1458.63, "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 $1,458.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 287.35, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 287.35, "10th_percentile": 287.35, "90th_percentile": 287.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 1166.9, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1166.9, "10th_percentile": 1166.9, "90th_percentile": 1166.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 697.23, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 697.23, "10th_percentile": 697.23, "90th_percentile": 697.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 697.23, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 697.23, "10th_percentile": 697.23, "90th_percentile": 697.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 697.23, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 697.23, "10th_percentile": 697.23, "90th_percentile": 697.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANCHOR HEALIX ADVANCE KNOTLESS 5.5MM", "code_information": [ { "code": "SUP-363194", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 323.1, "maximum": 1674.08, "setting": "outpatient", "gross_charge": 1674.08, "discounted_cash": 1171.86, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 882.24, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 517.29, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,674.08 @ 12.5% = $209.26 due to $0.00 Claim Price", "median_amount": 209.26, "10th_percentile": 209.26, "90th_percentile": 209.26, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,674.08 @ 12.5% = $209.26 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 567.51, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 567.51, "10th_percentile": 567.51, "90th_percentile": 567.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 597.31, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 597.31, "10th_percentile": 597.31, "90th_percentile": 597.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 837.04, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 837.04, "10th_percentile": 837.04, "90th_percentile": 837.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 329.79, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 329.79, "10th_percentile": 329.79, "90th_percentile": 329.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1255.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1255.56, "10th_percentile": 1255.56, "90th_percentile": 1255.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 890.61, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 890.61, "10th_percentile": 890.61, "90th_percentile": 890.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 1075.26, "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": 1075.26, "10th_percentile": 1075.26, "90th_percentile": 1075.26, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1674.08, "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 $1,674.08 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1674.08, "10th_percentile": 1674.08, "90th_percentile": 1674.08, "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 $1,674.08 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1054.67, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,054.67 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1054.67, "10th_percentile": 1054.67, "90th_percentile": 1054.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,054.67 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1171.86, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1171.86, "10th_percentile": 1171.86, "90th_percentile": 1171.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1674.08, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1674.08, "10th_percentile": 1674.08, "90th_percentile": 1674.08, "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": "NWR HFN PPO", "standard_charge_dollar": 1222.08, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1222.08, "10th_percentile": 1222.08, "90th_percentile": 1222.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 793.51, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 793.51, "10th_percentile": 793.51, "90th_percentile": 793.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 508.08, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 508.08, "10th_percentile": 508.08, "90th_percentile": 508.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 800.21, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 800.21, "10th_percentile": 800.21, "90th_percentile": 800.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 800.21, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 800.21, "10th_percentile": 800.21, "90th_percentile": 800.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 800.21, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 800.21, "10th_percentile": 800.21, "90th_percentile": 800.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 323.1, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1674.08, "10th_percentile": 1674.08, "90th_percentile": 1674.08, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1674.08, "10th_percentile": 1674.08, "90th_percentile": 1674.08, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 488.83, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 488.83, "10th_percentile": 488.83, "90th_percentile": 488.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 488.83, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 488.83, "10th_percentile": 488.83, "90th_percentile": 488.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 567.51, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 567.51, "10th_percentile": 567.51, "90th_percentile": 567.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 597.31, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 597.31, "10th_percentile": 597.31, "90th_percentile": 597.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 594.3, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 594.3, "10th_percentile": 594.3, "90th_percentile": 594.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1339.26, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1339.26, "10th_percentile": 1339.26, "90th_percentile": 1339.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 575.88, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 575.88, "10th_percentile": 575.88, "90th_percentile": 575.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" } ] } ] }, { "description": "ANCHOR KIT ACL TIGHTROPE AR-1588RT", "code_information": [ { "code": "SUP-135795", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 221.19, "maximum": 1146.06, "setting": "outpatient", "gross_charge": 1146.06, "discounted_cash": 802.24, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 221.19, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 603.97, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 354.13, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,146.06 @ 12.5% = $143.26 due to $0.00 Claim Price", "median_amount": 143.26, "10th_percentile": 143.26, "90th_percentile": 143.26, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,146.06 @ 12.5% = $143.26 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1146.06, "10th_percentile": 1146.06, "90th_percentile": 1146.06, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1146.06, "10th_percentile": 1146.06, "90th_percentile": 1146.06, "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": "NWR BCBS PPO", "standard_charge_dollar": 388.51, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 388.51, "10th_percentile": 388.51, "90th_percentile": 388.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 388.51, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 388.51, "10th_percentile": 388.51, "90th_percentile": 388.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 334.65, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 334.65, "10th_percentile": 334.65, "90th_percentile": 334.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 334.65, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 334.65, "10th_percentile": 334.65, "90th_percentile": 334.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 408.91, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 408.91, "10th_percentile": 408.91, "90th_percentile": 408.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 408.91, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 408.91, "10th_percentile": 408.91, "90th_percentile": 408.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 406.85, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 406.85, "10th_percentile": 406.85, "90th_percentile": 406.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 609.7, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 609.7, "10th_percentile": 609.7, "90th_percentile": 609.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 394.24, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 394.24, "10th_percentile": 394.24, "90th_percentile": 394.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 802.24, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 802.24, "10th_percentile": 802.24, "90th_percentile": 802.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 573.03, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 573.03, "10th_percentile": 573.03, "90th_percentile": 573.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 836.62, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 836.62, "10th_percentile": 836.62, "90th_percentile": 836.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 347.83, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 347.83, "10th_percentile": 347.83, "90th_percentile": 347.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1146.06, "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 $1,146.06 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1146.06, "10th_percentile": 1146.06, "90th_percentile": 1146.06, "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 $1,146.06 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 722.02, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $722.02 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 722.02, "10th_percentile": 722.02, "90th_percentile": 722.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $722.02 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1146.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1146.06, "10th_percentile": 1146.06, "90th_percentile": 1146.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 859.55, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 859.55, "10th_percentile": 859.55, "90th_percentile": 859.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 225.77, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 225.77, "10th_percentile": 225.77, "90th_percentile": 225.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 736.11, "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": 736.11, "10th_percentile": 736.11, "90th_percentile": 736.11, "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": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 916.85, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 916.85, "10th_percentile": 916.85, "90th_percentile": 916.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 543.23, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 543.23, "10th_percentile": 543.23, "90th_percentile": 543.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 547.82, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 547.82, "10th_percentile": 547.82, "90th_percentile": 547.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 547.82, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 547.82, "10th_percentile": 547.82, "90th_percentile": 547.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 547.82, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 547.82, "10th_percentile": 547.82, "90th_percentile": 547.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANCHOR KIT TIGHTROPE AR-1588TN-1", "code_information": [ { "code": "SUP-149362", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 160.72, "maximum": 832.75, "setting": "outpatient", "gross_charge": 832.75, "discounted_cash": 582.92, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 160.72, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 438.86, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 257.32, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $832.75 @ 12.5% = $104.09 due to $0.00 Claim Price", "median_amount": 104.09, "10th_percentile": 104.09, "90th_percentile": 104.09, "count": "0", "methodology": "other", "additional_payer_notes": "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: $832.75 @ 12.5% = $104.09 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 832.75, "10th_percentile": 832.75, "90th_percentile": 832.75, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 832.75, "10th_percentile": 832.75, "90th_percentile": 832.75, "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": "NWR BCBS PPO", "standard_charge_dollar": 282.3, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 282.3, "10th_percentile": 282.3, "90th_percentile": 282.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 282.3, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 282.3, "10th_percentile": 282.3, "90th_percentile": 282.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 243.16, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 243.16, "10th_percentile": 243.16, "90th_percentile": 243.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 243.16, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 243.16, "10th_percentile": 243.16, "90th_percentile": 243.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 297.13, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 297.13, "10th_percentile": 297.13, "90th_percentile": 297.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 297.13, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 297.13, "10th_percentile": 297.13, "90th_percentile": 297.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 295.63, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 295.63, "10th_percentile": 295.63, "90th_percentile": 295.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 443.02, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 443.02, "10th_percentile": 443.02, "90th_percentile": 443.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 286.47, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 286.47, "10th_percentile": 286.47, "90th_percentile": 286.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 582.93, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 582.93, "10th_percentile": 582.93, "90th_percentile": 582.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 416.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 416.38, "10th_percentile": 416.38, "90th_percentile": 416.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 607.91, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 607.91, "10th_percentile": 607.91, "90th_percentile": 607.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 252.74, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 252.74, "10th_percentile": 252.74, "90th_percentile": 252.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 832.75, "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 $832.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 832.75, "10th_percentile": 832.75, "90th_percentile": 832.75, "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 $832.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 524.63, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $524.63 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 524.63, "10th_percentile": 524.63, "90th_percentile": 524.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $524.63 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 832.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 832.75, "10th_percentile": 832.75, "90th_percentile": 832.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 624.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 624.56, "10th_percentile": 624.56, "90th_percentile": 624.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 164.05, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 164.05, "10th_percentile": 164.05, "90th_percentile": 164.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 534.88, "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": 534.88, "10th_percentile": 534.88, "90th_percentile": 534.88, "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": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 666.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 666.2, "10th_percentile": 666.2, "90th_percentile": 666.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 394.72, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 394.72, "10th_percentile": 394.72, "90th_percentile": 394.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 398.05, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 398.05, "10th_percentile": 398.05, "90th_percentile": 398.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 398.05, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 398.05, "10th_percentile": 398.05, "90th_percentile": 398.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 398.05, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 398.05, "10th_percentile": 398.05, "90th_percentile": 398.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANCHOR KIT TIGHTROPE RETROBUTTON EXTENDER 5 X 20MM AR-1589RT", "code_information": [ { "code": "SUP-312700", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 186.4, "maximum": 965.81, "setting": "outpatient", "gross_charge": 965.81, "discounted_cash": 676.07, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 508.98, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $965.81 @ 12.5% = $120.73 due to $0.00 Claim Price", "median_amount": 120.73, "10th_percentile": 120.73, "90th_percentile": 120.73, "count": "0", "methodology": "other", "additional_payer_notes": "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: $965.81 @ 12.5% = $120.73 due to $0.00 Claim Price" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 482.91, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 482.91, "10th_percentile": 482.91, "90th_percentile": 482.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 620.34, "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": 620.34, "10th_percentile": 620.34, "90th_percentile": 620.34, "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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 608.46, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $608.46 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 608.46, "10th_percentile": 608.46, "90th_percentile": 608.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $608.46 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 676.07, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 676.07, "10th_percentile": 676.07, "90th_percentile": 676.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 965.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 965.81, "10th_percentile": 965.81, "90th_percentile": 965.81, "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": "NWR HFN PPO", "standard_charge_dollar": 705.04, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 705.04, "10th_percentile": 705.04, "90th_percentile": 705.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 457.79, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 457.79, "10th_percentile": 457.79, "90th_percentile": 457.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 293.12, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 293.12, "10th_percentile": 293.12, "90th_percentile": 293.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 186.4, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 298.44, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 965.81, "10th_percentile": 965.81, "90th_percentile": 965.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 965.81, "10th_percentile": 965.81, "90th_percentile": 965.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 282.02, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 282.02, "10th_percentile": 282.02, "90th_percentile": 282.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 282.02, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 282.02, "10th_percentile": 282.02, "90th_percentile": 282.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 327.41, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 327.41, "10th_percentile": 327.41, "90th_percentile": 327.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 327.41, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 327.41, "10th_percentile": 327.41, "90th_percentile": 327.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 344.6, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 344.6, "10th_percentile": 344.6, "90th_percentile": 344.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 344.6, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 344.6, "10th_percentile": 344.6, "90th_percentile": 344.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 342.86, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 342.86, "10th_percentile": 342.86, "90th_percentile": 342.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 724.36, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 724.36, "10th_percentile": 724.36, "90th_percentile": 724.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 513.81, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 513.81, "10th_percentile": 513.81, "90th_percentile": 513.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 772.65, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 772.65, "10th_percentile": 772.65, "90th_percentile": 772.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 965.81, "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 $965.81 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 965.81, "10th_percentile": 965.81, "90th_percentile": 965.81, "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 $965.81 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 332.24, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 332.24, "10th_percentile": 332.24, "90th_percentile": 332.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 190.26, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 190.26, "10th_percentile": 190.26, "90th_percentile": 190.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 461.66, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 461.66, "10th_percentile": 461.66, "90th_percentile": 461.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 461.66, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 461.66, "10th_percentile": 461.66, "90th_percentile": 461.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 461.66, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 461.66, "10th_percentile": 461.66, "90th_percentile": 461.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANCHOR QUICK ANCHOR+ 212859", "code_information": [ { "code": "SUP-143056", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 384.47, "maximum": 1992.07, "setting": "outpatient", "gross_charge": 1992.07, "discounted_cash": 1394.45, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 384.47, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1049.82, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 615.55, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,992.07 @ 12.5% = $249.01 due to $0.00 Claim Price", "median_amount": 249.01, "10th_percentile": 249.01, "90th_percentile": 249.01, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,992.07 @ 12.5% = $249.01 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1992.07, "10th_percentile": 1992.07, "90th_percentile": 1992.07, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1992.07, "10th_percentile": 1992.07, "90th_percentile": 1992.07, "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": "NWR BCBS PPO", "standard_charge_dollar": 675.31, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 675.31, "10th_percentile": 675.31, "90th_percentile": 675.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 675.31, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 675.31, "10th_percentile": 675.31, "90th_percentile": 675.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 581.68, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 581.68, "10th_percentile": 581.68, "90th_percentile": 581.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 581.68, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 581.68, "10th_percentile": 581.68, "90th_percentile": 581.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 710.77, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 710.77, "10th_percentile": 710.77, "90th_percentile": 710.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 710.77, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 710.77, "10th_percentile": 710.77, "90th_percentile": 710.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 707.18, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 707.18, "10th_percentile": 707.18, "90th_percentile": 707.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1059.78, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1059.78, "10th_percentile": 1059.78, "90th_percentile": 1059.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 685.27, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 685.27, "10th_percentile": 685.27, "90th_percentile": 685.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1394.45, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1394.45, "10th_percentile": 1394.45, "90th_percentile": 1394.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 996.04, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 996.04, "10th_percentile": 996.04, "90th_percentile": 996.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1454.21, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1454.21, "10th_percentile": 1454.21, "90th_percentile": 1454.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 604.59, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 604.59, "10th_percentile": 604.59, "90th_percentile": 604.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1992.07, "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 $1,992.07 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1992.07, "10th_percentile": 1992.07, "90th_percentile": 1992.07, "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 $1,992.07 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1255.0, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,255.00 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1255.0, "10th_percentile": 1255.0, "90th_percentile": 1255.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,255.00 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1992.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1992.07, "10th_percentile": 1992.07, "90th_percentile": 1992.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1494.05, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1494.05, "10th_percentile": 1494.05, "90th_percentile": 1494.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 392.44, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 392.44, "10th_percentile": 392.44, "90th_percentile": 392.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 1279.51, "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": 1279.51, "10th_percentile": 1279.51, "90th_percentile": 1279.51, "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": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1593.66, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1593.66, "10th_percentile": 1593.66, "90th_percentile": 1593.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 944.24, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 944.24, "10th_percentile": 944.24, "90th_percentile": 944.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 952.21, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 952.21, "10th_percentile": 952.21, "90th_percentile": 952.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 952.21, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 952.21, "10th_percentile": 952.21, "90th_percentile": 952.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 952.21, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 952.21, "10th_percentile": 952.21, "90th_percentile": 952.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANCHOR STR 4.75MM SWVLCK SP PK KL", "code_information": [ { "code": "SUP-436754", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 398.14, "maximum": 2062.91, "setting": "outpatient", "gross_charge": 2062.91, "discounted_cash": 1444.04, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 398.14, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1087.15, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 637.44, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $2,062.91 @ 12.5% = $257.86 due to $0.00 Claim Price", "median_amount": 257.86, "10th_percentile": 257.86, "90th_percentile": 257.86, "count": "0", "methodology": "other", "additional_payer_notes": "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: $2,062.91 @ 12.5% = $257.86 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2062.91, "10th_percentile": 2062.91, "90th_percentile": 2062.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2062.91, "10th_percentile": 2062.91, "90th_percentile": 2062.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 602.37, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 602.37, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 699.33, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 699.33, "10th_percentile": 699.33, "90th_percentile": 699.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 699.33, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 699.33, "10th_percentile": 699.33, "90th_percentile": 699.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 736.05, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 736.05, "10th_percentile": 736.05, "90th_percentile": 736.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 736.05, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 736.05, "10th_percentile": 736.05, "90th_percentile": 736.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1444.04, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1444.04, "10th_percentile": 1444.04, "90th_percentile": 1444.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1031.46, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1031.46, "10th_percentile": 1031.46, "90th_percentile": 1031.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 732.33, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 732.33, "10th_percentile": 732.33, "90th_percentile": 732.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1547.18, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1547.18, "10th_percentile": 1547.18, "90th_percentile": 1547.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1505.92, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1505.92, "10th_percentile": 1505.92, "90th_percentile": 1505.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1097.47, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1097.47, "10th_percentile": 1097.47, "90th_percentile": 1097.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1650.33, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1650.33, "10th_percentile": 1650.33, "90th_percentile": 1650.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1299.63, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,299.63 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1299.63, "10th_percentile": 1299.63, "90th_percentile": 1299.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,299.63 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2062.91, "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 $2,062.91 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2062.91, "10th_percentile": 2062.91, "90th_percentile": 2062.91, "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 $2,062.91 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 626.09, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 626.09, "10th_percentile": 626.09, "90th_percentile": 626.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 709.64, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 709.64, "10th_percentile": 709.64, "90th_percentile": 709.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 977.82, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 977.82, "10th_percentile": 977.82, "90th_percentile": 977.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 406.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 406.39, "10th_percentile": 406.39, "90th_percentile": 406.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 1325.01, "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": 1325.01, "10th_percentile": 1325.01, "90th_percentile": 1325.01, "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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 2062.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2062.91, "10th_percentile": 2062.91, "90th_percentile": 2062.91, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 986.07, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 986.07, "10th_percentile": 986.07, "90th_percentile": 986.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 986.07, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 986.07, "10th_percentile": 986.07, "90th_percentile": 986.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 986.07, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 986.07, "10th_percentile": 986.07, "90th_percentile": 986.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANCHOR STR 5.5MM SWVLCK SP PEEK KL", "code_information": [ { "code": "SUP-438191", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 398.14, "maximum": 2062.91, "setting": "outpatient", "gross_charge": 2062.91, "discounted_cash": 1444.04, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 398.14, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2062.91, "10th_percentile": 2062.91, "90th_percentile": 2062.91, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2062.91, "10th_percentile": 2062.91, "90th_percentile": 2062.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 699.33, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 699.33, "10th_percentile": 699.33, "90th_percentile": 699.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 602.37, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 602.37, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 736.05, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 736.05, "10th_percentile": 736.05, "90th_percentile": 736.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 736.05, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 736.05, "10th_percentile": 736.05, "90th_percentile": 736.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 709.64, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 709.64, "10th_percentile": 709.64, "90th_percentile": 709.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1650.33, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1650.33, "10th_percentile": 1650.33, "90th_percentile": 1650.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 732.33, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 732.33, "10th_percentile": 732.33, "90th_percentile": 732.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2062.91, "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 $2,062.91 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2062.91, "10th_percentile": 2062.91, "90th_percentile": 2062.91, "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 $2,062.91 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": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 986.07, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 986.07, "10th_percentile": 986.07, "90th_percentile": 986.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 986.07, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 986.07, "10th_percentile": 986.07, "90th_percentile": 986.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 986.07, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 986.07, "10th_percentile": 986.07, "90th_percentile": 986.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1087.15, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 637.44, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $2,062.91 @ 12.5% = $257.86 due to $0.00 Claim Price", "median_amount": 257.86, "10th_percentile": 257.86, "90th_percentile": 257.86, "count": "0", "methodology": "other", "additional_payer_notes": "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: $2,062.91 @ 12.5% = $257.86 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 699.33, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 699.33, "10th_percentile": 699.33, "90th_percentile": 699.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1444.04, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1444.04, "10th_percentile": 1444.04, "90th_percentile": 1444.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1031.46, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1031.46, "10th_percentile": 1031.46, "90th_percentile": 1031.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1547.18, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1547.18, "10th_percentile": 1547.18, "90th_percentile": 1547.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1505.92, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1505.92, "10th_percentile": 1505.92, "90th_percentile": 1505.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1097.47, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1097.47, "10th_percentile": 1097.47, "90th_percentile": 1097.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1299.63, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,299.63 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1299.63, "10th_percentile": 1299.63, "90th_percentile": 1299.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,299.63 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 626.09, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 626.09, "10th_percentile": 626.09, "90th_percentile": 626.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 977.82, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 977.82, "10th_percentile": 977.82, "90th_percentile": 977.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 406.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 406.39, "10th_percentile": 406.39, "90th_percentile": 406.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 1325.01, "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": 1325.01, "10th_percentile": 1325.01, "90th_percentile": 1325.01, "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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 2062.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2062.91, "10th_percentile": 2062.91, "90th_percentile": 2062.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ANCHOR SUT 2.4MM HIP PEEK PUSHLOK AR-2924PHS", "code_information": [ { "code": "SUP-367004", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 314.81, "maximum": 1631.15, "setting": "outpatient", "gross_charge": 1631.15, "discounted_cash": 1141.8, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 504.03, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 314.81, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,631.15 @ 12.5% = $203.89 due to $0.00 Claim Price", "median_amount": 203.89, "10th_percentile": 203.89, "90th_percentile": 203.89, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,631.15 @ 12.5% = $203.89 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 552.96, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 552.96, "10th_percentile": 552.96, "90th_percentile": 552.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 552.96, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 552.96, "10th_percentile": 552.96, "90th_percentile": 552.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 476.3, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 476.3, "10th_percentile": 476.3, "90th_percentile": 476.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 476.3, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 476.3, "10th_percentile": 476.3, "90th_percentile": 476.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 581.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 581.99, "10th_percentile": 581.99, "90th_percentile": 581.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 581.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 581.99, "10th_percentile": 581.99, "90th_percentile": 581.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 561.12, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 561.12, "10th_percentile": 561.12, "90th_percentile": 561.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1304.92, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1304.92, "10th_percentile": 1304.92, "90th_percentile": 1304.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 579.06, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 579.06, "10th_percentile": 579.06, "90th_percentile": 579.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 321.34, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 321.34, "10th_percentile": 321.34, "90th_percentile": 321.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1223.36, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1223.36, "10th_percentile": 1223.36, "90th_percentile": 1223.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 867.77, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 867.77, "10th_percentile": 867.77, "90th_percentile": 867.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1631.15, "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 $1,631.15 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "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 $1,631.15 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1141.81, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1141.81, "10th_percentile": 1141.81, "90th_percentile": 1141.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1190.74, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1190.74, "10th_percentile": 1190.74, "90th_percentile": 1190.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 859.62, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 815.58, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 815.58, "10th_percentile": 815.58, "90th_percentile": 815.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 495.05, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 495.05, "10th_percentile": 495.05, "90th_percentile": 495.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1027.62, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,027.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1027.62, "10th_percentile": 1027.62, "90th_percentile": 1027.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,027.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1631.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 1047.69, "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": 1047.69, "10th_percentile": 1047.69, "90th_percentile": 1047.69, "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": "NWR UHC CORE", "standard_charge_dollar": 773.17, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 773.17, "10th_percentile": 773.17, "90th_percentile": 773.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "description": "ANCHOR SUT KNTLS BIO COMP PUSHLOCK 2.9X15.5MM STRL", "code_information": [ { "code": "SUP-135270", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 314.81, "maximum": 1631.15, "setting": "outpatient", "gross_charge": 1631.15, "discounted_cash": 1141.8, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 314.81, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 859.62, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 504.03, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,631.15 @ 12.5% = $203.89 due to $0.00 Claim Price", "median_amount": 203.89, "10th_percentile": 203.89, "90th_percentile": 203.89, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,631.15 @ 12.5% = $203.89 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 476.3, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 476.3, "10th_percentile": 476.3, "90th_percentile": 476.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 476.3, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 476.3, "10th_percentile": 476.3, "90th_percentile": 476.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 552.96, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 552.96, "10th_percentile": 552.96, "90th_percentile": 552.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 552.96, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 552.96, "10th_percentile": 552.96, "90th_percentile": 552.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 581.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 581.99, "10th_percentile": 581.99, "90th_percentile": 581.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 581.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 581.99, "10th_percentile": 581.99, "90th_percentile": 581.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1141.81, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1141.81, "10th_percentile": 1141.81, "90th_percentile": 1141.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 815.58, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 815.58, "10th_percentile": 815.58, "90th_percentile": 815.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 579.06, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 579.06, "10th_percentile": 579.06, "90th_percentile": 579.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1223.36, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1223.36, "10th_percentile": 1223.36, "90th_percentile": 1223.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1190.74, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1190.74, "10th_percentile": 1190.74, "90th_percentile": 1190.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 867.77, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 867.77, "10th_percentile": 867.77, "90th_percentile": 867.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1304.92, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1304.92, "10th_percentile": 1304.92, "90th_percentile": 1304.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1027.62, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,027.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1027.62, "10th_percentile": 1027.62, "90th_percentile": 1027.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,027.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1631.15, "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 $1,631.15 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "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 $1,631.15 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 495.05, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 495.05, "10th_percentile": 495.05, "90th_percentile": 495.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 561.12, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 561.12, "10th_percentile": 561.12, "90th_percentile": 561.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 773.17, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 773.17, "10th_percentile": 773.17, "90th_percentile": 773.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 321.34, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 321.34, "10th_percentile": 321.34, "90th_percentile": 321.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 1047.69, "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": 1047.69, "10th_percentile": 1047.69, "90th_percentile": 1047.69, "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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1631.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANCHOR SUT MENIS RAPIDLOC TOP HAT PNCRYL 2-0 CRV NDL 27DEG", "code_information": [ { "code": "SUP-57290", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 288.3, "maximum": 1493.79, "setting": "outpatient", "gross_charge": 1493.79, "discounted_cash": 1045.65, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 787.23, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 461.58, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 288.3, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,493.79 @ 12.5% = $186.72 due to $0.00 Claim Price", "median_amount": 186.72, "10th_percentile": 186.72, "90th_percentile": 186.72, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,493.79 @ 12.5% = $186.72 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1493.79, "10th_percentile": 1493.79, "90th_percentile": 1493.79, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1493.79, "10th_percentile": 1493.79, "90th_percentile": 1493.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 506.39, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 506.39, "10th_percentile": 506.39, "90th_percentile": 506.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 506.39, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 506.39, "10th_percentile": 506.39, "90th_percentile": 506.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 436.19, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 436.19, "10th_percentile": 436.19, "90th_percentile": 436.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 532.98, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 532.98, "10th_percentile": 532.98, "90th_percentile": 532.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 532.98, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 532.98, "10th_percentile": 532.98, "90th_percentile": 532.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 513.86, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 513.86, "10th_percentile": 513.86, "90th_percentile": 513.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 746.9, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 746.9, "10th_percentile": 746.9, "90th_percentile": 746.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1195.03, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1195.03, "10th_percentile": 1195.03, "90th_percentile": 1195.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 530.3, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 530.3, "10th_percentile": 530.3, "90th_percentile": 530.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 294.28, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 294.28, "10th_percentile": 294.28, "90th_percentile": 294.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1120.34, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1120.34, "10th_percentile": 1120.34, "90th_percentile": 1120.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 794.7, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 794.7, "10th_percentile": 794.7, "90th_percentile": 794.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 959.46, "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": 959.46, "10th_percentile": 959.46, "90th_percentile": 959.46, "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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1493.79, "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 $1,493.79 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1493.79, "10th_percentile": 1493.79, "90th_percentile": 1493.79, "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 $1,493.79 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 941.09, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $941.09 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 941.09, "10th_percentile": 941.09, "90th_percentile": 941.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $941.09 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1045.65, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1045.65, "10th_percentile": 1045.65, "90th_percentile": 1045.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1493.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1493.79, "10th_percentile": 1493.79, "90th_percentile": 1493.79, "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": "NWR HFN PPO", "standard_charge_dollar": 1090.47, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1090.47, "10th_percentile": 1090.47, "90th_percentile": 1090.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 708.06, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 708.06, "10th_percentile": 708.06, "90th_percentile": 708.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 453.37, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 453.37, "10th_percentile": 453.37, "90th_percentile": 453.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 714.03, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 714.03, "10th_percentile": 714.03, "90th_percentile": 714.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 714.03, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 714.03, "10th_percentile": 714.03, "90th_percentile": 714.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 714.03, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 714.03, "10th_percentile": 714.03, "90th_percentile": 714.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 436.19, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 436.19, "10th_percentile": 436.19, "90th_percentile": 436.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANCHOR SUT PEEK ZIP 5.5MM W/2 STRNDS 2 FF", "code_information": [ { "code": "SUP-139497", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 217.25, "maximum": 1125.64, "setting": "outpatient", "gross_charge": 1125.64, "discounted_cash": 787.95, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 217.25, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 593.21, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 347.82, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,125.64 @ 12.5% = $140.71 due to $0.00 Claim Price", "median_amount": 140.71, "10th_percentile": 140.71, "90th_percentile": 140.71, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,125.64 @ 12.5% = $140.71 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1125.64, "10th_percentile": 1125.64, "90th_percentile": 1125.64, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1125.64, "10th_percentile": 1125.64, "90th_percentile": 1125.64, "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": "NWR BCBS PPO", "standard_charge_dollar": 381.59, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 381.59, "10th_percentile": 381.59, "90th_percentile": 381.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 381.59, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 381.59, "10th_percentile": 381.59, "90th_percentile": 381.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 328.69, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 328.69, "10th_percentile": 328.69, "90th_percentile": 328.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 328.69, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 328.69, "10th_percentile": 328.69, "90th_percentile": 328.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 401.63, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 401.63, "10th_percentile": 401.63, "90th_percentile": 401.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 401.63, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 401.63, "10th_percentile": 401.63, "90th_percentile": 401.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 399.6, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 399.6, "10th_percentile": 399.6, "90th_percentile": 399.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 598.84, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 598.84, "10th_percentile": 598.84, "90th_percentile": 598.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 387.22, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 387.22, "10th_percentile": 387.22, "90th_percentile": 387.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 787.95, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 787.95, "10th_percentile": 787.95, "90th_percentile": 787.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 562.82, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 562.82, "10th_percentile": 562.82, "90th_percentile": 562.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 821.72, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 821.72, "10th_percentile": 821.72, "90th_percentile": 821.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 341.63, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 341.63, "10th_percentile": 341.63, "90th_percentile": 341.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1125.64, "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 $1,125.64 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1125.64, "10th_percentile": 1125.64, "90th_percentile": 1125.64, "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 $1,125.64 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 709.15, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $709.15 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 709.15, "10th_percentile": 709.15, "90th_percentile": 709.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $709.15 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1125.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1125.64, "10th_percentile": 1125.64, "90th_percentile": 1125.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 844.23, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 844.23, "10th_percentile": 844.23, "90th_percentile": 844.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 221.75, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 221.75, "10th_percentile": 221.75, "90th_percentile": 221.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 723.0, "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": 723.0, "10th_percentile": 723.0, "90th_percentile": 723.0, "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": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 900.51, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 900.51, "10th_percentile": 900.51, "90th_percentile": 900.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 533.55, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 533.55, "10th_percentile": 533.55, "90th_percentile": 533.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 538.06, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 538.06, "10th_percentile": 538.06, "90th_percentile": 538.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 538.06, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 538.06, "10th_percentile": 538.06, "90th_percentile": 538.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 538.06, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 538.06, "10th_percentile": 538.06, "90th_percentile": 538.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANCHOR SUT TENDSIS SWVL LOK 7MM PEEK", "code_information": [ { "code": "SUP-150136", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 314.81, "maximum": 1631.15, "setting": "outpatient", "gross_charge": 1631.15, "discounted_cash": 1141.8, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 314.81, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 859.62, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 504.03, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,631.15 @ 12.5% = $203.89 due to $0.00 Claim Price", "median_amount": 203.89, "10th_percentile": 203.89, "90th_percentile": 203.89, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,631.15 @ 12.5% = $203.89 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 476.3, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 476.3, "10th_percentile": 476.3, "90th_percentile": 476.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 476.3, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 476.3, "10th_percentile": 476.3, "90th_percentile": 476.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 552.96, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 552.96, "10th_percentile": 552.96, "90th_percentile": 552.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 552.96, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 552.96, "10th_percentile": 552.96, "90th_percentile": 552.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 581.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 581.99, "10th_percentile": 581.99, "90th_percentile": 581.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 581.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 581.99, "10th_percentile": 581.99, "90th_percentile": 581.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1141.81, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1141.81, "10th_percentile": 1141.81, "90th_percentile": 1141.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 815.58, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 815.58, "10th_percentile": 815.58, "90th_percentile": 815.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 579.06, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 579.06, "10th_percentile": 579.06, "90th_percentile": 579.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1223.36, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1223.36, "10th_percentile": 1223.36, "90th_percentile": 1223.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1190.74, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1190.74, "10th_percentile": 1190.74, "90th_percentile": 1190.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 867.77, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 867.77, "10th_percentile": 867.77, "90th_percentile": 867.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1304.92, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1304.92, "10th_percentile": 1304.92, "90th_percentile": 1304.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1027.62, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,027.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1027.62, "10th_percentile": 1027.62, "90th_percentile": 1027.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,027.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1631.15, "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 $1,631.15 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "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 $1,631.15 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 495.05, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 495.05, "10th_percentile": 495.05, "90th_percentile": 495.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 561.12, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 561.12, "10th_percentile": 561.12, "90th_percentile": 561.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 773.17, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 773.17, "10th_percentile": 773.17, "90th_percentile": 773.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 321.34, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 321.34, "10th_percentile": 321.34, "90th_percentile": 321.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 1047.69, "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": 1047.69, "10th_percentile": 1047.69, "90th_percentile": 1047.69, "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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1631.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANCHOR SUT TWINFIX ULT 4.5MM W/2 ULTBRD BLU BLK", "code_information": [ { "code": "SUP-131013", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 237.65, "maximum": 1231.35, "setting": "outpatient", "gross_charge": 1231.35, "discounted_cash": 861.94, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 237.65, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 648.92, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 380.49, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,231.35 @ 12.5% = $153.92 due to $0.00 Claim Price", "median_amount": 153.92, "10th_percentile": 153.92, "90th_percentile": 153.92, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,231.35 @ 12.5% = $153.92 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1231.35, "10th_percentile": 1231.35, "90th_percentile": 1231.35, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1231.35, "10th_percentile": 1231.35, "90th_percentile": 1231.35, "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": "NWR BCBS PPO", "standard_charge_dollar": 417.43, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 417.43, "10th_percentile": 417.43, "90th_percentile": 417.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 417.43, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 417.43, "10th_percentile": 417.43, "90th_percentile": 417.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 359.55, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 359.55, "10th_percentile": 359.55, "90th_percentile": 359.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 359.55, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 359.55, "10th_percentile": 359.55, "90th_percentile": 359.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 439.35, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 439.35, "10th_percentile": 439.35, "90th_percentile": 439.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 439.35, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 439.35, "10th_percentile": 439.35, "90th_percentile": 439.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 437.13, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 437.13, "10th_percentile": 437.13, "90th_percentile": 437.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 655.08, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 655.08, "10th_percentile": 655.08, "90th_percentile": 655.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 423.58, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 423.58, "10th_percentile": 423.58, "90th_percentile": 423.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 861.95, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 861.95, "10th_percentile": 861.95, "90th_percentile": 861.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 615.68, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 615.68, "10th_percentile": 615.68, "90th_percentile": 615.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 898.89, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 898.89, "10th_percentile": 898.89, "90th_percentile": 898.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 373.71, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 373.71, "10th_percentile": 373.71, "90th_percentile": 373.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1231.35, "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 $1,231.35 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1231.35, "10th_percentile": 1231.35, "90th_percentile": 1231.35, "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 $1,231.35 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 775.75, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $775.75 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 775.75, "10th_percentile": 775.75, "90th_percentile": 775.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $775.75 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1231.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1231.35, "10th_percentile": 1231.35, "90th_percentile": 1231.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 923.51, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 923.51, "10th_percentile": 923.51, "90th_percentile": 923.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 242.58, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 242.58, "10th_percentile": 242.58, "90th_percentile": 242.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 790.9, "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": 790.9, "10th_percentile": 790.9, "90th_percentile": 790.9, "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": "NWR BEECHSTREET", "standard_charge_dollar": 985.08, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 985.08, "10th_percentile": 985.08, "90th_percentile": 985.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 583.66, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 583.66, "10th_percentile": 583.66, "90th_percentile": 583.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 588.59, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 588.59, "10th_percentile": 588.59, "90th_percentile": 588.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 588.59, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 588.59, "10th_percentile": 588.59, "90th_percentile": 588.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 588.59, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 588.59, "10th_percentile": 588.59, "90th_percentile": 588.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANCHOR SUTURE 2.9X12.5MM BIOCOMPOSITE PEEK PUSHLOCK", "code_information": [ { "code": "SUP-345420", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 347.95, "maximum": 1802.85, "setting": "outpatient", "gross_charge": 1802.85, "discounted_cash": 1261.99, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 950.1, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1135.8, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,135.80 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1135.8, "10th_percentile": 1135.8, "90th_percentile": 1135.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,135.80 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 854.55, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 854.55, "10th_percentile": 854.55, "90th_percentile": 854.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 1157.97, "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": 1157.97, "10th_percentile": 1157.97, "90th_percentile": 1157.97, "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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 347.95, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 557.08, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,802.85 @ 12.5% = $225.36 due to $0.00 Claim Price", "median_amount": 225.36, "10th_percentile": 225.36, "90th_percentile": 225.36, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,802.85 @ 12.5% = $225.36 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1802.85, "10th_percentile": 1802.85, "90th_percentile": 1802.85, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1802.85, "10th_percentile": 1802.85, "90th_percentile": 1802.85, "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": "NWR BCBS PPO", "standard_charge_dollar": 611.17, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 611.17, "10th_percentile": 611.17, "90th_percentile": 611.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 611.17, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 611.17, "10th_percentile": 611.17, "90th_percentile": 611.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 526.43, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 526.43, "10th_percentile": 526.43, "90th_percentile": 526.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 526.43, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 526.43, "10th_percentile": 526.43, "90th_percentile": 526.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 643.26, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 643.26, "10th_percentile": 643.26, "90th_percentile": 643.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 643.26, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 643.26, "10th_percentile": 643.26, "90th_percentile": 643.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 640.01, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 640.01, "10th_percentile": 640.01, "90th_percentile": 640.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 959.12, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 959.12, "10th_percentile": 959.12, "90th_percentile": 959.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 620.18, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 620.18, "10th_percentile": 620.18, "90th_percentile": 620.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1262.0, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1262.0, "10th_percentile": 1262.0, "90th_percentile": 1262.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 901.43, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 901.43, "10th_percentile": 901.43, "90th_percentile": 901.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1316.08, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1316.08, "10th_percentile": 1316.08, "90th_percentile": 1316.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 547.16, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 547.16, "10th_percentile": 547.16, "90th_percentile": 547.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1802.85, "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 $1,802.85 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1802.85, "10th_percentile": 1802.85, "90th_percentile": 1802.85, "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 $1,802.85 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1802.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1802.85, "10th_percentile": 1802.85, "90th_percentile": 1802.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1352.14, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1352.14, "10th_percentile": 1352.14, "90th_percentile": 1352.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 355.16, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 355.16, "10th_percentile": 355.16, "90th_percentile": 355.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 1442.28, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1442.28, "10th_percentile": 1442.28, "90th_percentile": 1442.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 861.76, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 861.76, "10th_percentile": 861.76, "90th_percentile": 861.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 861.76, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 861.76, "10th_percentile": 861.76, "90th_percentile": 861.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 861.76, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 861.76, "10th_percentile": 861.76, "90th_percentile": 861.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANCHOR SUTURE 3.9X17.9MM PEEK SWIVELOCK", "code_information": [ { "code": "SUP-345342", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 301.62, "maximum": 1562.81, "setting": "outpatient", "gross_charge": 1562.81, "discounted_cash": 1093.97, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 823.6, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 482.91, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,562.81 @ 12.5% = $195.35 due to $0.00 Claim Price", "median_amount": 195.35, "10th_percentile": 195.35, "90th_percentile": 195.35, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,562.81 @ 12.5% = $195.35 due to $0.00 Claim Price" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 781.41, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 781.41, "10th_percentile": 781.41, "90th_percentile": 781.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 307.87, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 307.87, "10th_percentile": 307.87, "90th_percentile": 307.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1172.11, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1172.11, "10th_percentile": 1172.11, "90th_percentile": 1172.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 831.41, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 831.41, "10th_percentile": 831.41, "90th_percentile": 831.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 1003.79, "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": 1003.79, "10th_percentile": 1003.79, "90th_percentile": 1003.79, "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": "NWR PHCS PPO", "standard_charge_dollar": 984.57, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $984.57 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 984.57, "10th_percentile": 984.57, "90th_percentile": 984.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $984.57 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1093.97, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1093.97, "10th_percentile": 1093.97, "90th_percentile": 1093.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1562.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1562.81, "10th_percentile": 1562.81, "90th_percentile": 1562.81, "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": "NWR HFN PPO", "standard_charge_dollar": 1140.85, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1140.85, "10th_percentile": 1140.85, "90th_percentile": 1140.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 740.77, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 740.77, "10th_percentile": 740.77, "90th_percentile": 740.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 474.31, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 474.31, "10th_percentile": 474.31, "90th_percentile": 474.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 301.62, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1562.81, "10th_percentile": 1562.81, "90th_percentile": 1562.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1562.81, "10th_percentile": 1562.81, "90th_percentile": 1562.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 456.34, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 456.34, "10th_percentile": 456.34, "90th_percentile": 456.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 456.34, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 456.34, "10th_percentile": 456.34, "90th_percentile": 456.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 529.79, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 529.79, "10th_percentile": 529.79, "90th_percentile": 529.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 529.79, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 529.79, "10th_percentile": 529.79, "90th_percentile": 529.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 557.61, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 557.61, "10th_percentile": 557.61, "90th_percentile": 557.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 557.61, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 557.61, "10th_percentile": 557.61, "90th_percentile": 557.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 554.8, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 554.8, "10th_percentile": 554.8, "90th_percentile": 554.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1250.25, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1250.25, "10th_percentile": 1250.25, "90th_percentile": 1250.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1562.81, "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 $1,562.81 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1562.81, "10th_percentile": 1562.81, "90th_percentile": 1562.81, "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 $1,562.81 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 537.61, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 537.61, "10th_percentile": 537.61, "90th_percentile": 537.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 747.02, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 747.02, "10th_percentile": 747.02, "90th_percentile": 747.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 747.02, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 747.02, "10th_percentile": 747.02, "90th_percentile": 747.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 747.02, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 747.02, "10th_percentile": 747.02, "90th_percentile": 747.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANCHOR SUTURE 4.75X22MM PEEK DBL LOAD SWIVELOCK", "code_information": [ { "code": "SUP-354770", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 327.24, "maximum": 1695.54, "setting": "outpatient", "gross_charge": 1695.54, "discounted_cash": 1186.88, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 327.24, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 893.55, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 523.92, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,695.54 @ 12.5% = $211.94 due to $0.00 Claim Price", "median_amount": 211.94, "10th_percentile": 211.94, "90th_percentile": 211.94, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,695.54 @ 12.5% = $211.94 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1695.54, "10th_percentile": 1695.54, "90th_percentile": 1695.54, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1695.54, "10th_percentile": 1695.54, "90th_percentile": 1695.54, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 495.1, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 495.1, "10th_percentile": 495.1, "90th_percentile": 495.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 495.1, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 495.1, "10th_percentile": 495.1, "90th_percentile": 495.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 574.79, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 574.79, "10th_percentile": 574.79, "90th_percentile": 574.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 574.79, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 574.79, "10th_percentile": 574.79, "90th_percentile": 574.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 604.97, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 604.97, "10th_percentile": 604.97, "90th_percentile": 604.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 604.97, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 604.97, "10th_percentile": 604.97, "90th_percentile": 604.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1186.88, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1186.88, "10th_percentile": 1186.88, "90th_percentile": 1186.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 847.77, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 847.77, "10th_percentile": 847.77, "90th_percentile": 847.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 601.92, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 601.92, "10th_percentile": 601.92, "90th_percentile": 601.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1271.66, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1271.66, "10th_percentile": 1271.66, "90th_percentile": 1271.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1237.74, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1237.74, "10th_percentile": 1237.74, "90th_percentile": 1237.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 902.03, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 902.03, "10th_percentile": 902.03, "90th_percentile": 902.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1356.43, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1356.43, "10th_percentile": 1356.43, "90th_percentile": 1356.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1068.19, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,068.19 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1068.19, "10th_percentile": 1068.19, "90th_percentile": 1068.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,068.19 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1695.54, "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 $1,695.54 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1695.54, "10th_percentile": 1695.54, "90th_percentile": 1695.54, "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 $1,695.54 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 514.6, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 514.6, "10th_percentile": 514.6, "90th_percentile": 514.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 583.27, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 583.27, "10th_percentile": 583.27, "90th_percentile": 583.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 803.69, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 803.69, "10th_percentile": 803.69, "90th_percentile": 803.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 334.02, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 334.02, "10th_percentile": 334.02, "90th_percentile": 334.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 1089.05, "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": 1089.05, "10th_percentile": 1089.05, "90th_percentile": 1089.05, "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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1695.54, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1695.54, "10th_percentile": 1695.54, "90th_percentile": 1695.54, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 810.47, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 810.47, "10th_percentile": 810.47, "90th_percentile": 810.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 810.47, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 810.47, "10th_percentile": 810.47, "90th_percentile": 810.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 810.47, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 810.47, "10th_percentile": 810.47, "90th_percentile": 810.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANCHOR SUTURE SWIVEL LOCK 5.5X19.1MM PEEK", "code_information": [ { "code": "SUP-362956", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 285.54, "maximum": 1479.46, "setting": "outpatient", "gross_charge": 1479.46, "discounted_cash": 1035.62, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 779.68, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 457.15, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 285.54, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,479.46 @ 12.5% = $184.93 due to $0.00 Claim Price", "median_amount": 184.93, "10th_percentile": 184.93, "90th_percentile": 184.93, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,479.46 @ 12.5% = $184.93 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1479.46, "10th_percentile": 1479.46, "90th_percentile": 1479.46, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1479.46, "10th_percentile": 1479.46, "90th_percentile": 1479.46, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 501.54, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 501.54, "10th_percentile": 501.54, "90th_percentile": 501.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 501.54, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 501.54, "10th_percentile": 501.54, "90th_percentile": 501.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 432.0, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 432.0, "10th_percentile": 432.0, "90th_percentile": 432.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 432.0, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 432.0, "10th_percentile": 432.0, "90th_percentile": 432.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 527.87, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 527.87, "10th_percentile": 527.87, "90th_percentile": 527.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 527.87, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 527.87, "10th_percentile": 527.87, "90th_percentile": 527.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 508.93, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 508.93, "10th_percentile": 508.93, "90th_percentile": 508.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 739.73, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 739.73, "10th_percentile": 739.73, "90th_percentile": 739.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1183.57, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1183.57, "10th_percentile": 1183.57, "90th_percentile": 1183.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 525.21, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 525.21, "10th_percentile": 525.21, "90th_percentile": 525.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 291.45, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 291.45, "10th_percentile": 291.45, "90th_percentile": 291.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1109.6, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1109.6, "10th_percentile": 1109.6, "90th_percentile": 1109.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 787.07, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 787.07, "10th_percentile": 787.07, "90th_percentile": 787.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 950.26, "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": 950.26, "10th_percentile": 950.26, "90th_percentile": 950.26, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1479.46, "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 $1,479.46 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1479.46, "10th_percentile": 1479.46, "90th_percentile": 1479.46, "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 $1,479.46 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 932.06, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $932.06 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 932.06, "10th_percentile": 932.06, "90th_percentile": 932.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $932.06 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1035.62, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1035.62, "10th_percentile": 1035.62, "90th_percentile": 1035.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1479.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1479.46, "10th_percentile": 1479.46, "90th_percentile": 1479.46, "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": "NWR HFN PPO", "standard_charge_dollar": 1080.01, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1080.01, "10th_percentile": 1080.01, "90th_percentile": 1080.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 701.26, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 701.26, "10th_percentile": 701.26, "90th_percentile": 701.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 449.02, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 449.02, "10th_percentile": 449.02, "90th_percentile": 449.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 707.18, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 707.18, "10th_percentile": 707.18, "90th_percentile": 707.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 707.18, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 707.18, "10th_percentile": 707.18, "90th_percentile": 707.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 707.18, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 707.18, "10th_percentile": 707.18, "90th_percentile": 707.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANCHOR SUTURETAK 3.0MM AR-1934BCFT", "code_information": [ { "code": "SUP-25401", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 261.41, "maximum": 1354.44, "setting": "outpatient", "gross_charge": 1354.44, "discounted_cash": 948.11, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 261.41, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 713.79, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 418.52, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,354.44 @ 12.5% = $169.31 due to $0.00 Claim Price", "median_amount": 169.31, "10th_percentile": 169.31, "90th_percentile": 169.31, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,354.44 @ 12.5% = $169.31 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1354.44, "10th_percentile": 1354.44, "90th_percentile": 1354.44, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1354.44, "10th_percentile": 1354.44, "90th_percentile": 1354.44, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 395.5, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 395.5, "10th_percentile": 395.5, "90th_percentile": 395.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 395.5, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 395.5, "10th_percentile": 395.5, "90th_percentile": 395.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 459.16, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 459.16, "10th_percentile": 459.16, "90th_percentile": 459.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 459.16, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 459.16, "10th_percentile": 459.16, "90th_percentile": 459.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 483.26, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 483.26, "10th_percentile": 483.26, "90th_percentile": 483.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 483.26, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 483.26, "10th_percentile": 483.26, "90th_percentile": 483.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 948.11, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 948.11, "10th_percentile": 948.11, "90th_percentile": 948.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 677.22, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 677.22, "10th_percentile": 677.22, "90th_percentile": 677.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 480.83, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 480.83, "10th_percentile": 480.83, "90th_percentile": 480.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1015.83, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1015.83, "10th_percentile": 1015.83, "90th_percentile": 1015.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 988.74, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 988.74, "10th_percentile": 988.74, "90th_percentile": 988.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 720.56, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 720.56, "10th_percentile": 720.56, "90th_percentile": 720.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1083.55, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1083.55, "10th_percentile": 1083.55, "90th_percentile": 1083.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 853.3, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $853.30 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 853.3, "10th_percentile": 853.3, "90th_percentile": 853.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $853.30 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1354.44, "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 $1,354.44 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1354.44, "10th_percentile": 1354.44, "90th_percentile": 1354.44, "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 $1,354.44 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 411.07, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 411.07, "10th_percentile": 411.07, "90th_percentile": 411.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 465.93, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 465.93, "10th_percentile": 465.93, "90th_percentile": 465.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 642.0, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 642.0, "10th_percentile": 642.0, "90th_percentile": 642.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 266.82, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 266.82, "10th_percentile": 266.82, "90th_percentile": 266.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 869.96, "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": 869.96, "10th_percentile": 869.96, "90th_percentile": 869.96, "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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1354.44, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1354.44, "10th_percentile": 1354.44, "90th_percentile": 1354.44, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 647.42, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 647.42, "10th_percentile": 647.42, "90th_percentile": 647.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 647.42, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 647.42, "10th_percentile": 647.42, "90th_percentile": 647.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 647.42, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 647.42, "10th_percentile": 647.42, "90th_percentile": 647.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANCHOR TWINFIX 5.0MM 72200755", "code_information": [ { "code": "SUP-123701", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 203.21, "maximum": 1052.88, "setting": "outpatient", "gross_charge": 1052.88, "discounted_cash": 737.02, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 203.21, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 554.87, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 325.34, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,052.88 @ 12.5% = $131.61 due to $0.00 Claim Price", "median_amount": 131.61, "10th_percentile": 131.61, "90th_percentile": 131.61, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,052.88 @ 12.5% = $131.61 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1052.88, "10th_percentile": 1052.88, "90th_percentile": 1052.88, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1052.88, "10th_percentile": 1052.88, "90th_percentile": 1052.88, "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": "NWR BCBS PPO", "standard_charge_dollar": 356.93, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 356.93, "10th_percentile": 356.93, "90th_percentile": 356.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 356.93, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 356.93, "10th_percentile": 356.93, "90th_percentile": 356.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 307.44, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 307.44, "10th_percentile": 307.44, "90th_percentile": 307.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 307.44, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 307.44, "10th_percentile": 307.44, "90th_percentile": 307.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 375.67, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 375.67, "10th_percentile": 375.67, "90th_percentile": 375.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 375.67, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 375.67, "10th_percentile": 375.67, "90th_percentile": 375.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 373.77, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 373.77, "10th_percentile": 373.77, "90th_percentile": 373.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 560.13, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 560.13, "10th_percentile": 560.13, "90th_percentile": 560.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 362.19, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 362.19, "10th_percentile": 362.19, "90th_percentile": 362.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 737.02, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 737.02, "10th_percentile": 737.02, "90th_percentile": 737.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 526.44, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 526.44, "10th_percentile": 526.44, "90th_percentile": 526.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 768.6, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 768.6, "10th_percentile": 768.6, "90th_percentile": 768.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 319.55, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 319.55, "10th_percentile": 319.55, "90th_percentile": 319.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1052.88, "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 $1,052.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1052.88, "10th_percentile": 1052.88, "90th_percentile": 1052.88, "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 $1,052.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 663.31, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $663.31 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 663.31, "10th_percentile": 663.31, "90th_percentile": 663.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $663.31 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1052.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1052.88, "10th_percentile": 1052.88, "90th_percentile": 1052.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 789.66, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 789.66, "10th_percentile": 789.66, "90th_percentile": 789.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 207.42, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 207.42, "10th_percentile": 207.42, "90th_percentile": 207.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 676.26, "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": 676.26, "10th_percentile": 676.26, "90th_percentile": 676.26, "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": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 842.3, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 842.3, "10th_percentile": 842.3, "90th_percentile": 842.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 499.07, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 499.07, "10th_percentile": 499.07, "90th_percentile": 499.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 503.28, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 503.28, "10th_percentile": 503.28, "90th_percentile": 503.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 503.28, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 503.28, "10th_percentile": 503.28, "90th_percentile": 503.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 503.28, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 503.28, "10th_percentile": 503.28, "90th_percentile": 503.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ANES TEMPRERATURE PROBE SKIN", "code_information": [ { "code": "SUP-308891", "type": "CDM" }, { "code": "27000001", "type": "LOCAL" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "minimum": 129.45, "maximum": 670.7, "setting": "outpatient", "gross_charge": 670.7, "discounted_cash": 469.49, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 239.31, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 239.31, "10th_percentile": 239.31, "90th_percentile": 239.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 239.31, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 239.31, "10th_percentile": 239.31, "90th_percentile": 239.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 188.4, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 188.4, "10th_percentile": 188.4, "90th_percentile": 188.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 188.4, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 188.4, "10th_percentile": 188.4, "90th_percentile": 188.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 197.79, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 197.79, "10th_percentile": 197.79, "90th_percentile": 197.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 670.7, "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 $670.70 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 670.7, "10th_percentile": 670.7, "90th_percentile": 670.7, "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 $670.70 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": "NWR BCBS PPO", "standard_charge_dollar": 261.24, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 261.24, "10th_percentile": 261.24, "90th_percentile": 261.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 326.63, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 326.63, "10th_percentile": 326.63, "90th_percentile": 326.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 230.72, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 230.72, "10th_percentile": 230.72, "90th_percentile": 230.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 352.12, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 352.12, "10th_percentile": 352.12, "90th_percentile": 352.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 238.1, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 238.1, "10th_percentile": 238.1, "90th_percentile": 238.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 129.45, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 129.45, "10th_percentile": 129.45, "90th_percentile": 129.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 261.24, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 261.24, "10th_percentile": 261.24, "90th_percentile": 261.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 536.56, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 536.56, "10th_percentile": 536.56, "90th_percentile": 536.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 356.81, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 356.81, "10th_percentile": 356.81, "90th_percentile": 356.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 132.13, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 132.13, "10th_percentile": 132.13, "90th_percentile": 132.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 670.7, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 670.7, "10th_percentile": 670.7, "90th_percentile": 670.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 503.03, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 503.03, "10th_percentile": 503.03, "90th_percentile": 503.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 207.25, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 207.25, "10th_percentile": 207.25, "90th_percentile": 207.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 469.49, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 469.49, "10th_percentile": 469.49, "90th_percentile": 469.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 489.61, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 489.61, "10th_percentile": 489.61, "90th_percentile": 489.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 335.35, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 335.35, "10th_percentile": 335.35, "90th_percentile": 335.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 203.56, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 203.56, "10th_percentile": 203.56, "90th_percentile": 203.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 422.54, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $422.54 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 422.54, "10th_percentile": 422.54, "90th_percentile": 422.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $422.54 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 430.79, "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": 430.79, "10th_percentile": 430.79, "90th_percentile": 430.79, "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": "NWR UHC CORE", "standard_charge_dollar": 317.91, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 317.91, "10th_percentile": 317.91, "90th_percentile": 317.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 353.46, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 353.46, "10th_percentile": 353.46, "90th_percentile": 353.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 670.7, "10th_percentile": 670.7, "90th_percentile": 670.7, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 670.7, "10th_percentile": 670.7, "90th_percentile": 670.7, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 670.7, "10th_percentile": 670.7, "90th_percentile": 670.7, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "ANGIOCCLUDE MED TIT 6/CT 30CT/BX", "code_information": [ { "code": "SUP-446615", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 0.46, "maximum": 2.37, "setting": "outpatient", "gross_charge": 2.37, "discounted_cash": 1.66, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.37, "10th_percentile": 2.37, "90th_percentile": 2.37, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.92, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 0.85, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 1.15, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.46, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.46, "10th_percentile": 0.46, "90th_percentile": 0.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1.24, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.24, "10th_percentile": 1.24, "90th_percentile": 1.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.84, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.84, "10th_percentile": 0.84, "90th_percentile": 0.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.82, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.82, "10th_percentile": 0.82, "90th_percentile": 0.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.37, "10th_percentile": 2.37, "90th_percentile": 2.37, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.37, "10th_percentile": 2.37, "90th_percentile": 2.37, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.67, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.67, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.85, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.92, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 1.52, "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": 1.52, "10th_percentile": 1.52, "90th_percentile": 1.52, "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": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.78, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1.78, "10th_percentile": 1.78, "90th_percentile": 1.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.7, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": 0.7, "90th_percentile": 0.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.72, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.72, "10th_percentile": 0.72, "90th_percentile": 0.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 1.12, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1.12, "10th_percentile": 1.12, "90th_percentile": 1.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.73, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.73, "10th_percentile": 1.73, "90th_percentile": 1.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.26, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.26, "10th_percentile": 1.26, "90th_percentile": 1.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.49, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.49 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1.49, "10th_percentile": 1.49, "90th_percentile": 1.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.49 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.37, "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 $2.37 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.37, "10th_percentile": 2.37, "90th_percentile": 2.37, "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 $2.37 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.37, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% 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 OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.47, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.25, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1.19, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.19, "10th_percentile": 1.19, "90th_percentile": 1.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1.9, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.9, "10th_percentile": 1.9, "90th_percentile": 1.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.73, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.73, "10th_percentile": 0.73, "90th_percentile": 0.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.66, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1.66, "10th_percentile": 1.66, "90th_percentile": 1.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" } ] } ] }, { "description": "ANGIOPLASTY PACK LARGE BORE", "code_information": [ { "code": "SUP-11249", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 10.6, "maximum": 54.94, "setting": "outpatient", "gross_charge": 54.94, "discounted_cash": 38.46, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 54.94, "10th_percentile": 54.94, "90th_percentile": 54.94, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 54.94, "10th_percentile": 54.94, "90th_percentile": 54.94, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 54.94, "10th_percentile": 54.94, "90th_percentile": 54.94, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 21.4, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.4, "10th_percentile": 21.4, "90th_percentile": 21.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 21.4, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.4, "10th_percentile": 21.4, "90th_percentile": 21.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 19.6, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.6, "10th_percentile": 19.6, "90th_percentile": 19.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 19.6, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.6, "10th_percentile": 19.6, "90th_percentile": 19.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 15.43, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.43, "10th_percentile": 15.43, "90th_percentile": 15.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 15.43, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.43, "10th_percentile": 15.43, "90th_percentile": 15.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 26.76, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.76, "10th_percentile": 26.76, "90th_percentile": 26.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 10.6, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 10.6, "10th_percentile": 10.6, "90th_percentile": 10.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 28.84, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.84, "10th_percentile": 28.84, "90th_percentile": 28.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 19.5, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 19.5, "10th_percentile": 19.5, "90th_percentile": 19.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 18.9, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 18.9, "10th_percentile": 18.9, "90th_percentile": 18.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 29.23, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 29.23, "10th_percentile": 29.23, "90th_percentile": 29.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 26.04, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 26.04, "10th_percentile": 26.04, "90th_percentile": 26.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 16.67, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 16.67, "10th_percentile": 16.67, "90th_percentile": 16.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 35.29, "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": 35.29, "10th_percentile": 35.29, "90th_percentile": 35.29, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 10.82, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.82, "10th_percentile": 10.82, "90th_percentile": 10.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 43.95, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 43.95, "10th_percentile": 43.95, "90th_percentile": 43.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 28.95, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.95, "10th_percentile": 28.95, "90th_percentile": 28.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 54.94, "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 $54.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 54.94, "10th_percentile": 54.94, "90th_percentile": 54.94, "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 $54.94 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 34.61, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $34.61 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 34.61, "10th_percentile": 34.61, "90th_percentile": 34.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $34.61 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 16.2, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.2, "10th_percentile": 16.2, "90th_percentile": 16.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 41.21, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 41.21, "10th_percentile": 41.21, "90th_percentile": 41.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 38.46, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 38.46, "10th_percentile": 38.46, "90th_percentile": 38.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 40.11, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 40.11, "10th_percentile": 40.11, "90th_percentile": 40.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 16.98, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.98, "10th_percentile": 16.98, "90th_percentile": 16.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 54.94, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 54.94, "10th_percentile": 54.94, "90th_percentile": 54.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 27.47, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 27.47, "10th_percentile": 27.47, "90th_percentile": 27.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" } ] } ] }, { "description": "ANOSCOPE DISPOSABLE (SANISCOPE)", "code_information": [ { "code": "SUP-121355", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 0.74, "maximum": 3.81, "setting": "outpatient", "gross_charge": 3.81, "discounted_cash": 2.67, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3.81, "10th_percentile": 3.81, "90th_percentile": 3.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3.81, "10th_percentile": 3.81, "90th_percentile": 3.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3.81, "10th_percentile": 3.81, "90th_percentile": 3.81, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.07, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.07, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.36, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 1.36, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1.48, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.48, "10th_percentile": 1.48, "90th_percentile": 1.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1.48, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.48, "10th_percentile": 1.48, "90th_percentile": 1.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1.35, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1.35, "10th_percentile": 1.35, "90th_percentile": 1.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 2.0, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 1.31, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1.31, "10th_percentile": 1.31, "90th_percentile": 1.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 1.86, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.74, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.74, "10th_percentile": 0.74, "90th_percentile": 0.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 2.45, "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": 2.45, "10th_percentile": 2.45, "90th_percentile": 2.45, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2.86, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 2.86, "10th_percentile": 2.86, "90th_percentile": 2.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.12, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 1.16, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 1.16, "10th_percentile": 1.16, "90th_percentile": 1.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 1.81, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1.81, "10th_percentile": 1.81, "90th_percentile": 1.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 2.78, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 2.78, "10th_percentile": 2.78, "90th_percentile": 2.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 2.03, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 2.03, "10th_percentile": 2.03, "90th_percentile": 2.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 2.4, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2.40 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 2.4, "10th_percentile": 2.4, "90th_percentile": 2.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2.40 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3.81, "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 $3.81 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3.81, "10th_percentile": 3.81, "90th_percentile": 3.81, "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 $3.81 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3.81, "10th_percentile": 3.81, "90th_percentile": 3.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.75, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 2.01, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1.91, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% 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 Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 3.05, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 3.05, "10th_percentile": 3.05, "90th_percentile": 3.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 1.18, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2.67, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 2.67, "10th_percentile": 2.67, "90th_percentile": 2.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" } ] } ] }, { "description": "ANTENNA ABLATION 2.8X15CM PERC", "code_information": [ { "code": "SUP-341610", "type": "CDM" }, { "code": "C1886", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 2319.67, "maximum": 12019.0, "setting": "outpatient", "gross_charge": 12019.0, "discounted_cash": 8413.3, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 4074.44, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4074.44, "10th_percentile": 4074.44, "90th_percentile": 4074.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 4074.44, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4074.44, "10th_percentile": 4074.44, "90th_percentile": 4074.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 4288.38, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4288.38, "10th_percentile": 4288.38, "90th_percentile": 4288.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 4288.38, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4288.38, "10th_percentile": 4288.38, "90th_percentile": 4288.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 6309.98, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6309.98, "10th_percentile": 6309.98, "90th_percentile": 6309.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 2319.67, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 2319.67, "10th_percentile": 2319.67, "90th_percentile": 2319.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 4266.75, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 4266.75, "10th_percentile": 4266.75, "90th_percentile": 4266.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 5853.25, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5853.25, "10th_percentile": 5853.25, "90th_percentile": 5853.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 4134.54, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 4134.54, "10th_percentile": 4134.54, "90th_percentile": 4134.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 3647.77, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 3647.77, "10th_percentile": 3647.77, "90th_percentile": 3647.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 9615.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 9615.2, "10th_percentile": 9615.2, "90th_percentile": 9615.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 6394.11, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 6394.11, "10th_percentile": 6394.11, "90th_percentile": 6394.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 8773.87, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 8773.87, "10th_percentile": 8773.87, "90th_percentile": 8773.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 9014.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 9014.25, "10th_percentile": 9014.25, "90th_percentile": 9014.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 8413.3, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 8413.3, "10th_percentile": 8413.3, "90th_percentile": 8413.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 2367.74, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2367.74, "10th_percentile": 2367.74, "90th_percentile": 2367.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 12019.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12019.0, "10th_percentile": 12019.0, "90th_percentile": 12019.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 6009.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 6009.5, "10th_percentile": 6009.5, "90th_percentile": 6009.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 5697.01, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 5697.01, "10th_percentile": 5697.01, "90th_percentile": 5697.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 7719.8, "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": 7719.8, "10th_percentile": 7719.8, "90th_percentile": 7719.8, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 3713.87, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3713.87, "10th_percentile": 3713.87, "90th_percentile": 3713.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 6334.01, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6334.01, "10th_percentile": 6334.01, "90th_percentile": 6334.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 12019.0, "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 $12,019.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 12019.0, "10th_percentile": 12019.0, "90th_percentile": 12019.0, "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 $12,019.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 7571.97, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $7,571.97 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 7571.97, "10th_percentile": 7571.97, "90th_percentile": 7571.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $7,571.97 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5745.08, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5745.08, "10th_percentile": 5745.08, "90th_percentile": 5745.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5745.08, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5745.08, "10th_percentile": 5745.08, "90th_percentile": 5745.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5745.08, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5745.08, "10th_percentile": 5745.08, "90th_percentile": 5745.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12019.0, "10th_percentile": 12019.0, "90th_percentile": 12019.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12019.0, "10th_percentile": 12019.0, "90th_percentile": 12019.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $12,019.00 @ 12.5% = $1,502.38 due to $0.00 Claim Price", "median_amount": 1502.38, "10th_percentile": 1502.38, "90th_percentile": 1502.38, "count": "0", "methodology": "other", "additional_payer_notes": "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: $12,019.00 @ 12.5% = $1,502.38 due to $0.00 Claim Price" } ] } ] }, { "description": "AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC", "code_information": [ { "code": "269", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 30051.58, "maximum": 51632.84, "setting": "inpatient", "gross_charge": 139373.2, "discounted_cash": 97561.25, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_percentage": 53.1, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Stop Loss; 53.1% 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": 74010.1, "10th_percentile": 74010.1, "90th_percentile": 74010.1, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_percentage": 19.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 26900.12, "10th_percentile": 26900.12, "90th_percentile": 26900.12, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_percentage": 36.1, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient; 36.1% Billed", "median_amount": 50315.72, "10th_percentile": 50315.72, "90th_percentile": 50315.72, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_percentage": 34.5, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient; 34.5% Billed", "median_amount": 48085.66, "10th_percentile": 48085.66, "90th_percentile": 48085.66, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Stop Loss; 70% Billed", "median_amount": 97565.1, "10th_percentile": 97565.1, "90th_percentile": 97565.1, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_percentage": 73.0, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All Inpatient Services; 73% Billed", "median_amount": 101746.47, "10th_percentile": 101746.47, "90th_percentile": 101746.47, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 71.3, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; IP Services. ADP RATE (for patient estimates only); 71.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 99377.03, "10th_percentile": 99377.03, "90th_percentile": 99377.03, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient; 80% Billed", "median_amount": 111502.98, "10th_percentile": 111502.98, "90th_percentile": 111502.98, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_percentage": 50.8, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient; 50.8% Billed", "median_amount": 70804.39, "10th_percentile": 70804.39, "90th_percentile": 70804.39, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient; 30.35% Billed", "median_amount": 42301.44, "10th_percentile": 42301.44, "90th_percentile": 42301.44, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; 100% Billed", "median_amount": 139378.72, "10th_percentile": 139378.72, "90th_percentile": 139378.72, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient Services; 50% Billed", "median_amount": 69689.36, "10th_percentile": 69689.36, "90th_percentile": 69689.36, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "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": 104534.05, "10th_percentile": 104534.05, "90th_percentile": 104534.05, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 51632.84, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 4.2232, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 268823.5, "10th_percentile": 268823.5, "90th_percentile": 268823.5, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 33118.33, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 4.2232, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 33118.33, "10th_percentile": 33118.33, "90th_percentile": 33118.33, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 51632.84, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 4.2232, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 268823.5, "10th_percentile": 268823.5, "90th_percentile": 268823.5, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 33118.33, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 4.2232, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 33118.33, "10th_percentile": 33118.33, "90th_percentile": 33118.33, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 34448.64, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 4.2232, Rate: 8,157.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 34448.64, "10th_percentile": 34448.64, "90th_percentile": 34448.64, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 33118.33, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 4.2232, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 33118.33, "10th_percentile": 33118.33, "90th_percentile": 33118.33, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 33781.38, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 4.2232, Rate: 7,999.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 33781.38, "10th_percentile": 33781.38, "90th_percentile": 33781.38, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 30051.58, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 4.22, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $33,483.62; Total: $33,483.62 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33483.62, "10th_percentile": 33483.62, "90th_percentile": 33483.62, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 4.22, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $33,483.62; Total: $33,483.62 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_dollar": 30051.58, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 4.22, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $33,483.62; Total: $33,483.62 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33483.62, "10th_percentile": 33483.62, "90th_percentile": 33483.62, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 4.22, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $33,483.62; Total: $33,483.62 Paid at contractual rate, which is the lesser 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": "NWR MEDICARE", "standard_charge_dollar": 30051.58, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 4.22, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $35,620.09; Total: $35,620.09", "median_amount": 35620.09, "10th_percentile": 35620.09, "90th_percentile": 35620.09, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 4.22, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $35,620.09; Total: $35,620.09" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 45935.75, "standard_charge_algorithm": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 4.2232, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid $87,808.59 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 87808.59, "10th_percentile": 87808.59, "90th_percentile": 87808.59, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.870635662; Using historical claim(s); Scope: All Financial Classes; Cases: 1; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 4.2232, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid $87,808.59 so that total pmt for all claim lines does not exceed 63% of claim billed amount." } ] } ] }, { "description": "AORTIC VALVE AVALUS BOVINE PERICARDIAL 27MM", "code_information": [ { "code": "SUP-358606", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 4142.26, "maximum": 21462.5, "setting": "outpatient", "gross_charge": 21462.5, "discounted_cash": 15023.75, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $21,462.50 @ 12.5% = $2,682.81 due to $0.00 Claim Price", "median_amount": 2682.81, "10th_percentile": 2682.81, "90th_percentile": 2682.81, "count": "0", "methodology": "other", "additional_payer_notes": "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: $21,462.50 @ 12.5% = $2,682.81 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 21462.5, "10th_percentile": 21462.5, "90th_percentile": 21462.5, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 21462.5, "10th_percentile": 21462.5, "90th_percentile": 21462.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 7383.1, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 7383.1, "10th_percentile": 7383.1, "90th_percentile": 7383.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 10731.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 10731.25, "10th_percentile": 10731.25, "90th_percentile": 10731.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 4228.11, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4228.11, "10th_percentile": 4228.11, "90th_percentile": 4228.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 15667.63, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 15667.63, "10th_percentile": 15667.63, "90th_percentile": 15667.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 6513.87, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 6513.87, "10th_percentile": 6513.87, "90th_percentile": 6513.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 10173.23, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 10173.23, "10th_percentile": 10173.23, "90th_percentile": 10173.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 16096.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 16096.88, "10th_percentile": 16096.88, "90th_percentile": 16096.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 7619.19, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 7619.19, "10th_percentile": 7619.19, "90th_percentile": 7619.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 13785.36, "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": 13785.36, "10th_percentile": 13785.36, "90th_percentile": 13785.36, "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": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 17170.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 17170.0, "10th_percentile": 17170.0, "90th_percentile": 17170.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 11418.05, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 11418.05, "10th_percentile": 11418.05, "90th_percentile": 11418.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 6631.91, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6631.91, "10th_percentile": 6631.91, "90th_percentile": 6631.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 15023.75, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 15023.75, "10th_percentile": 15023.75, "90th_percentile": 15023.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 21462.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 21462.5, "10th_percentile": 21462.5, "90th_percentile": 21462.5, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 21462.5, "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 $21,462.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 21462.5, "10th_percentile": 21462.5, "90th_percentile": 21462.5, "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 $21,462.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 13521.38, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $13,521.38 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 13521.38, "10th_percentile": 13521.38, "90th_percentile": 13521.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $13,521.38 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 11310.74, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.47, "10th_percentile": 45.47, "90th_percentile": 45.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 4142.26, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 8.1, "10th_percentile": 8.1, "90th_percentile": 8.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 7275.79, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7275.79, "10th_percentile": 7275.79, "90th_percentile": 7275.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 7275.79, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7275.79, "10th_percentile": 7275.79, "90th_percentile": 7275.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 7657.82, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7657.82, "10th_percentile": 7657.82, "90th_percentile": 7657.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 7657.82, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7657.82, "10th_percentile": 7657.82, "90th_percentile": 7657.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 6267.05, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6267.05, "10th_percentile": 6267.05, "90th_percentile": 6267.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 6267.05, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6267.05, "10th_percentile": 6267.05, "90th_percentile": 6267.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10259.08, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10259.08, "10th_percentile": 10259.08, "90th_percentile": 10259.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 10259.08, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10259.08, "10th_percentile": 10259.08, "90th_percentile": 10259.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 10259.08, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10259.08, "10th_percentile": 10259.08, "90th_percentile": 10259.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "APEX RX BALLOON 2.0 X 40MM", "code_information": [ { "code": "SUP-313882", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 70.42, "maximum": 364.86, "setting": "outpatient", "gross_charge": 364.86, "discounted_cash": 255.4, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 71.88, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.88, "10th_percentile": 71.88, "90th_percentile": 71.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 291.89, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 291.89, "10th_percentile": 291.89, "90th_percentile": 291.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 129.53, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 129.53, "10th_percentile": 129.53, "90th_percentile": 129.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 112.74, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 97.08, "10th_percentile": 97.08, "90th_percentile": 97.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 266.35, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 266.35, "10th_percentile": 266.35, "90th_percentile": 266.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 255.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 255.4, "10th_percentile": 255.4, "90th_percentile": 255.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 234.35, "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": 234.35, "10th_percentile": 234.35, "90th_percentile": 234.35, "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": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 191.55, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 191.55, "10th_percentile": 191.55, "90th_percentile": 191.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 192.28, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 192.28, "10th_percentile": 192.28, "90th_percentile": 192.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 125.51, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 125.51, "10th_percentile": 125.51, "90th_percentile": 125.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 273.65, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 273.65, "10th_percentile": 273.65, "90th_percentile": 273.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 194.11, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 194.11, "10th_percentile": 194.11, "90th_percentile": 194.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 110.74, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 110.74, "10th_percentile": 110.74, "90th_percentile": 110.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 182.43, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 182.43, "10th_percentile": 182.43, "90th_percentile": 182.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 172.94, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 172.94, "10th_percentile": 172.94, "90th_percentile": 172.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 177.69, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 177.69, "10th_percentile": 177.69, "90th_percentile": 177.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 70.42, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 70.42, "10th_percentile": 70.42, "90th_percentile": 70.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 229.86, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $229.86 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 229.86, "10th_percentile": 229.86, "90th_percentile": 229.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $229.86 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 364.86, "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 $364.86 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "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 $364.86 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 364.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "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": "NWR BCBS HMO", "standard_charge_dollar": 130.18, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 130.18, "10th_percentile": 130.18, "90th_percentile": 130.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 130.18, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 130.18, "10th_percentile": 130.18, "90th_percentile": 130.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 123.69, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 123.69, "10th_percentile": 123.69, "90th_percentile": 123.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 123.69, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 123.69, "10th_percentile": 123.69, "90th_percentile": 123.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 174.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.4, "10th_percentile": 174.4, "90th_percentile": 174.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 174.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.4, "10th_percentile": 174.4, "90th_percentile": 174.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 174.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.4, "10th_percentile": 174.4, "90th_percentile": 174.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $364.86 @ 12.5% = $45.61 due to $0.00 Claim Price", "median_amount": 45.61, "10th_percentile": 45.61, "90th_percentile": 45.61, "count": "0", "methodology": "other", "additional_payer_notes": "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: $364.86 @ 12.5% = $45.61 due to $0.00 Claim Price" } ] } ] }, { "description": "APPENDIX PROCEDURES WITHOUT CC/MCC", "code_information": [ { "code": "399", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 8145.49, "maximum": 13995.1, "setting": "inpatient", "gross_charge": 56973.81, "discounted_cash": 39881.67, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 13995.1, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 58011.91, "10th_percentile": 58011.91, "90th_percentile": 58011.91, "count": "34", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 9156.46, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 7,999.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 9156.46, "10th_percentile": 9156.46, "90th_percentile": 9156.46, "count": "34", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 8976.74, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 8976.74, "10th_percentile": 8976.74, "90th_percentile": 8976.74, "count": "34", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 9337.32, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 8,157.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 64903.44, "10th_percentile": 64903.44, "90th_percentile": 64903.44, "count": "34", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 8976.74, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 61244.09, "10th_percentile": 61244.09, "90th_percentile": 61244.09, "count": "34", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 8976.74, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 61244.09, "10th_percentile": 61244.09, "90th_percentile": 61244.09, "count": "34", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 13995.1, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 58011.91, "10th_percentile": 58011.91, "90th_percentile": 58011.91, "count": "34", "methodology": "case rate" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 42734.13, "10th_percentile": 42734.13, "90th_percentile": 42734.13, "count": "34", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_percentage": 50.8, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; Inpatient; 50.8% Billed", "median_amount": 28945.24, "10th_percentile": 28945.24, "90th_percentile": 28945.24, "count": "34", "methodology": "percent of total billed charges" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; Inpatient; 30.35% Billed", "median_amount": 17293.07, "10th_percentile": 17293.07, "90th_percentile": 17293.07, "count": "34", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; Inpatient Services; 50% Billed", "median_amount": 28489.41, "10th_percentile": 28489.41, "90th_percentile": 28489.41, "count": "34", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; All IP Services; 100% Billed", "median_amount": 56978.82, "10th_percentile": 56978.82, "90th_percentile": 56978.82, "count": "34", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; Inpatient; 80% Billed", "median_amount": 45583.06, "10th_percentile": 45583.06, "90th_percentile": 45583.06, "count": "34", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 71.3, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; IP Services. ADP RATE (for patient estimates only); 71.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40625.9, "10th_percentile": 40625.9, "90th_percentile": 40625.9, "count": "34", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; Stop Loss; 70% Billed", "median_amount": 39885.17, "10th_percentile": 39885.17, "90th_percentile": 39885.17, "count": "34", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_percentage": 73.0, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; All Inpatient Services; 73% Billed", "median_amount": 41594.54, "10th_percentile": 41594.54, "90th_percentile": 41594.54, "count": "34", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_percentage": 36.1, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; Inpatient; 36.1% Billed", "median_amount": 20569.35, "10th_percentile": 20569.35, "90th_percentile": 20569.35, "count": "34", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_percentage": 34.5, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; Inpatient; 34.5% Billed", "median_amount": 19657.69, "10th_percentile": 19657.69, "90th_percentile": 19657.69, "count": "34", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_percentage": 19.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 11045.45, "10th_percentile": 11045.45, "90th_percentile": 11045.45, "count": "34", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 12450.9, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 63% of charges. Total pmt for all lines paid so far is less than 63% of claim billed amount.", "median_amount": 12450.9, "10th_percentile": 12450.9, "90th_percentile": 12450.9, "count": "34", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 63% of charges. Total pmt for all lines paid so far is less than 63% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_dollar": 8145.49, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $9,365.83; Total: $9,365.83", "median_amount": 9365.83, "10th_percentile": 9365.83, "90th_percentile": 9365.83, "count": "34", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; All DRGs (Plans excl O-IME); FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALCULATION EXCL O-IME; Note: Base payment: $9,365.83; Total: $9,365.83" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_dollar": 8145.49, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $9,365.83; Total: $9,365.83 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9365.83, "10th_percentile": 9365.83, "90th_percentile": 9365.83, "count": "34", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $9,365.83; Total: $9,365.83 Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 8145.49, "standard_charge_algorithm": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $9,365.83; Total: $9,365.83 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9365.83, "10th_percentile": 9365.83, "90th_percentile": 9365.83, "count": "34", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.781276341; Using historical claim(s); Scope: All Financial Classes; Cases: 34; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $9,365.83; Total: $9,365.83 Paid at contractual rate, which is 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": "APPLICATOR KT SL HEMST FBRN EXT SPRY TIS 5X40MM 0601130", "code_information": [ { "code": "SUP-338111", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 80.75, "maximum": 418.37, "setting": "outpatient", "gross_charge": 418.37, "discounted_cash": 292.86, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 418.37, "10th_percentile": 418.37, "90th_percentile": 418.37, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 418.37, "10th_percentile": 418.37, "90th_percentile": 418.37, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 418.37, "10th_percentile": 418.37, "90th_percentile": 418.37, "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": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 117.52, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 117.52, "10th_percentile": 117.52, "90th_percentile": 117.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 117.52, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 117.52, "10th_percentile": 117.52, "90th_percentile": 117.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 162.96, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 162.96, "10th_percentile": 162.96, "90th_percentile": 162.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 162.96, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 162.96, "10th_percentile": 162.96, "90th_percentile": 162.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 149.27, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 149.27, "10th_percentile": 149.27, "90th_percentile": 149.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 149.27, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 149.27, "10th_percentile": 149.27, "90th_percentile": 149.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 148.52, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 148.52, "10th_percentile": 148.52, "90th_percentile": 148.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 143.92, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 143.92, "10th_percentile": 143.92, "90th_percentile": 143.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 203.75, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 203.75, "10th_percentile": 203.75, "90th_percentile": 203.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 80.75, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 80.75, "10th_percentile": 80.75, "90th_percentile": 80.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 219.64, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 219.64, "10th_percentile": 219.64, "90th_percentile": 219.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 418.37, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 418.37, "10th_percentile": 418.37, "90th_percentile": 418.37, "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 123.38, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 123.38, "10th_percentile": 123.38, "90th_percentile": 123.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 209.19, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 209.19, "10th_percentile": 209.19, "90th_percentile": 209.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 292.86, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 292.86, "10th_percentile": 292.86, "90th_percentile": 292.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 305.41, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 305.41, "10th_percentile": 305.41, "90th_percentile": 305.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 220.48, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 220.48, "10th_percentile": 220.48, "90th_percentile": 220.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 126.98, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 126.98, "10th_percentile": 126.98, "90th_percentile": 126.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 263.57, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $263.57 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 263.57, "10th_percentile": 263.57, "90th_percentile": 263.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $263.57 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 418.37, "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 $418.37 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 418.37, "10th_percentile": 418.37, "90th_percentile": 418.37, "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 $418.37 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 82.42, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 82.42, "10th_percentile": 82.42, "90th_percentile": 82.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 334.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 334.7, "10th_percentile": 334.7, "90th_percentile": 334.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 129.28, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 129.28, "10th_percentile": 129.28, "90th_percentile": 129.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 313.78, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 313.78, "10th_percentile": 313.78, "90th_percentile": 313.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 222.57, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 222.57, "10th_percentile": 222.57, "90th_percentile": 222.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 268.72, "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": 268.72, "10th_percentile": 268.72, "90th_percentile": 268.72, "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": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 198.31, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 198.31, "10th_percentile": 198.31, "90th_percentile": 198.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "description": "ARACHNOID KNIFE 2\" BAYONET SIDECUTTING (AM-24-SB)", "code_information": [ { "code": "SUP-338006", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 132.55, "maximum": 686.8, "setting": "outpatient", "gross_charge": 686.8, "discounted_cash": 480.76, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 686.8, "10th_percentile": 686.8, "90th_percentile": 686.8, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 245.05, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.05, "10th_percentile": 245.05, "90th_percentile": 245.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 243.81, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 243.81, "10th_percentile": 243.81, "90th_percentile": 243.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 360.57, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 360.57, "10th_percentile": 360.57, "90th_percentile": 360.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 236.26, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 236.26, "10th_percentile": 236.26, "90th_percentile": 236.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 334.47, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 334.47, "10th_percentile": 334.47, "90th_percentile": 334.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 132.55, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 132.55, "10th_percentile": 132.55, "90th_percentile": 132.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 686.8, "10th_percentile": 686.8, "90th_percentile": 686.8, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 686.8, "10th_percentile": 686.8, "90th_percentile": 686.8, "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": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 192.92, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 192.92, "10th_percentile": 192.92, "90th_percentile": 192.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 192.92, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 192.92, "10th_percentile": 192.92, "90th_percentile": 192.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 267.51, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 267.51, "10th_percentile": 267.51, "90th_percentile": 267.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 267.51, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 267.51, "10th_percentile": 267.51, "90th_percentile": 267.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 245.05, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.05, "10th_percentile": 245.05, "90th_percentile": 245.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 686.8, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 686.8, "10th_percentile": 686.8, "90th_percentile": 686.8, "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 202.54, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 202.54, "10th_percentile": 202.54, "90th_percentile": 202.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 343.4, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 343.4, "10th_percentile": 343.4, "90th_percentile": 343.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 480.76, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 480.76, "10th_percentile": 480.76, "90th_percentile": 480.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 501.36, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 501.36, "10th_percentile": 501.36, "90th_percentile": 501.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 361.94, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 361.94, "10th_percentile": 361.94, "90th_percentile": 361.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 208.44, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 208.44, "10th_percentile": 208.44, "90th_percentile": 208.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 432.68, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $432.68 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 432.68, "10th_percentile": 432.68, "90th_percentile": 432.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $432.68 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 686.8, "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 $686.80 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 686.8, "10th_percentile": 686.8, "90th_percentile": 686.8, "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 $686.80 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 135.3, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 135.3, "10th_percentile": 135.3, "90th_percentile": 135.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 549.44, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 549.44, "10th_percentile": 549.44, "90th_percentile": 549.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 212.22, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 212.22, "10th_percentile": 212.22, "90th_percentile": 212.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 515.1, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 515.1, "10th_percentile": 515.1, "90th_percentile": 515.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 365.38, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 365.38, "10th_percentile": 365.38, "90th_percentile": 365.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 441.13, "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": 441.13, "10th_percentile": 441.13, "90th_percentile": 441.13, "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": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 325.54, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 325.54, "10th_percentile": 325.54, "90th_percentile": 325.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "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": 60.32, "maximum": 312.56, "setting": "outpatient", "gross_charge": 312.56, "discounted_cash": 218.79, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 96.58, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 60.32, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $312.56 @ 12.5% = $39.07 due to $0.00 Claim Price", "median_amount": 39.07, "10th_percentile": 39.07, "90th_percentile": 39.07, "count": "0", "methodology": "other", "additional_payer_notes": "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: $312.56 @ 12.5% = $39.07 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 312.56, "10th_percentile": 312.56, "90th_percentile": 312.56, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 312.56, "10th_percentile": 312.56, "90th_percentile": 312.56, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 105.96, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 105.96, "10th_percentile": 105.96, "90th_percentile": 105.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 105.96, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 105.96, "10th_percentile": 105.96, "90th_percentile": 105.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 91.27, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 91.27, "10th_percentile": 91.27, "90th_percentile": 91.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 91.27, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 91.27, "10th_percentile": 91.27, "90th_percentile": 91.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 111.52, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 111.52, "10th_percentile": 111.52, "90th_percentile": 111.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 111.52, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 111.52, "10th_percentile": 111.52, "90th_percentile": 111.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 107.52, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 107.52, "10th_percentile": 107.52, "90th_percentile": 107.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 156.28, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 156.28, "10th_percentile": 156.28, "90th_percentile": 156.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 250.05, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 250.05, "10th_percentile": 250.05, "90th_percentile": 250.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 110.96, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 110.96, "10th_percentile": 110.96, "90th_percentile": 110.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 61.57, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.57, "10th_percentile": 61.57, "90th_percentile": 61.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 234.42, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 234.42, "10th_percentile": 234.42, "90th_percentile": 234.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 166.28, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 166.28, "10th_percentile": 166.28, "90th_percentile": 166.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 200.76, "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": 200.76, "10th_percentile": 200.76, "90th_percentile": 200.76, "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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 312.56, "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 $312.56 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 312.56, "10th_percentile": 312.56, "90th_percentile": 312.56, "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 $312.56 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 196.91, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $196.91 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 196.91, "10th_percentile": 196.91, "90th_percentile": 196.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $196.91 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 218.79, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 218.79, "10th_percentile": 218.79, "90th_percentile": 218.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 312.56, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 312.56, "10th_percentile": 312.56, "90th_percentile": 312.56, "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": "NWR HFN PPO", "standard_charge_dollar": 228.17, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 228.17, "10th_percentile": 228.17, "90th_percentile": 228.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 94.86, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 94.86, "10th_percentile": 94.86, "90th_percentile": 94.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 149.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 149.4, "10th_percentile": 149.4, "90th_percentile": 149.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 149.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 149.4, "10th_percentile": 149.4, "90th_percentile": 149.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 149.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 149.4, "10th_percentile": 149.4, "90th_percentile": 149.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 164.72, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 148.15, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 148.15, "10th_percentile": 148.15, "90th_percentile": 148.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "description": "ARFORMOTEROL 15 MCG/2 ML INH NEBU", "drug_information": { "unit": 2.0, "type": "ML" }, "code_information": [ { "code": "RX-100571", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "69097-0168-87", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.9, "maximum": 15.0, "setting": "outpatient", "gross_charge": 15.0, "discounted_cash": 10.5, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 15.0, "10th_percentile": 15.0, "90th_percentile": 15.0, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 15.0, "10th_percentile": 15.0, "90th_percentile": 15.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 15.0, "10th_percentile": 15.0, "90th_percentile": 15.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 5.35, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.35, "10th_percentile": 5.35, "90th_percentile": 5.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 5.35, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.35, "10th_percentile": 5.35, "90th_percentile": 5.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 5.84, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.84, "10th_percentile": 5.84, "90th_percentile": 5.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 5.84, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.84, "10th_percentile": 5.84, "90th_percentile": 5.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4.21, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.21, "10th_percentile": 4.21, "90th_percentile": 4.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4.21, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.21, "10th_percentile": 4.21, "90th_percentile": 4.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 7.31, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.31, "10th_percentile": 7.31, "90th_percentile": 7.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 5.16, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 5.16, "10th_percentile": 5.16, "90th_percentile": 5.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 7.88, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.88, "10th_percentile": 7.88, "90th_percentile": 7.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 5.33, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 5.33, "10th_percentile": 5.33, "90th_percentile": 5.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 2.9, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% 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; 19.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 15.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 15.0, "10th_percentile": 15.0, "90th_percentile": 15.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 12.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 7.98, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 7.98, "10th_percentile": 7.98, "90th_percentile": 7.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 2.96, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 11.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 11.25, "10th_percentile": 11.25, "90th_percentile": 11.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 4.64, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.64, "10th_percentile": 4.64, "90th_percentile": 4.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 10.5, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 10.5, "10th_percentile": 10.5, "90th_percentile": 10.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 10.95, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 10.95, "10th_percentile": 10.95, "90th_percentile": 10.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 7.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 7.5, "10th_percentile": 7.5, "90th_percentile": 7.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 4.55, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 4.55, "10th_percentile": 4.55, "90th_percentile": 4.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 9.45, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $9.45 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $9.45 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 9.63, "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": 9.63, "10th_percentile": 9.63, "90th_percentile": 9.63, "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": "NWR UHC CORE", "standard_charge_dollar": 7.11, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 7.11, "10th_percentile": 7.11, "90th_percentile": 7.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 7.91, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.91, "10th_percentile": 7.91, "90th_percentile": 7.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4.42, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 15.0, "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 $15.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 15.0, "10th_percentile": 15.0, "90th_percentile": 15.0, "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 $15.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." } ] } ] }, { "description": "ARFORMOTEROL 15 MCG/2 ML INH NEBU", "drug_information": { "unit": 2.0, "type": "ML" }, "code_information": [ { "code": "RX-100571", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "70436-0151-57", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.85, "maximum": 14.75, "setting": "outpatient", "gross_charge": 14.75, "discounted_cash": 10.32, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14.75, "10th_percentile": 14.75, "90th_percentile": 14.75, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14.75, "10th_percentile": 14.75, "90th_percentile": 14.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14.75, "10th_percentile": 14.75, "90th_percentile": 14.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 5.26, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.26, "10th_percentile": 5.26, "90th_percentile": 5.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 5.26, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.26, "10th_percentile": 5.26, "90th_percentile": 5.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 5.75, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 5.75, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4.14, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.14, "10th_percentile": 4.14, "90th_percentile": 4.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4.14, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.14, "10th_percentile": 4.14, "90th_percentile": 4.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 7.18, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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 Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 5.07, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 5.07, "10th_percentile": 5.07, "90th_percentile": 5.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 7.74, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.74, "10th_percentile": 7.74, "90th_percentile": 7.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 5.24, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 5.24, "10th_percentile": 5.24, "90th_percentile": 5.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 2.85, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 2.85, "10th_percentile": 2.85, "90th_percentile": 2.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 11.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 11.8, "10th_percentile": 11.8, "90th_percentile": 11.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4.35, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.35, "10th_percentile": 4.35, "90th_percentile": 4.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 14.75, "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 $14.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 14.75, "10th_percentile": 14.75, "90th_percentile": 14.75, "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 $14.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 7.85, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 7.85, "10th_percentile": 7.85, "90th_percentile": 7.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 2.91, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.91, "10th_percentile": 2.91, "90th_percentile": 2.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 11.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 11.06, "10th_percentile": 11.06, "90th_percentile": 11.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 4.56, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.56, "10th_percentile": 4.56, "90th_percentile": 4.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 10.33, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 10.33, "10th_percentile": 10.33, "90th_percentile": 10.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 10.77, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 10.77, "10th_percentile": 10.77, "90th_percentile": 10.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 7.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 7.38, "10th_percentile": 7.38, "90th_percentile": 7.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 4.48, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 4.48, "10th_percentile": 4.48, "90th_percentile": 4.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 9.29, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $9.29 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 9.29, "10th_percentile": 9.29, "90th_percentile": 9.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $9.29 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 9.47, "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": 9.47, "10th_percentile": 9.47, "90th_percentile": 9.47, "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": "NWR UHC CORE", "standard_charge_dollar": 6.99, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 6.99, "10th_percentile": 6.99, "90th_percentile": 6.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 7.77, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.77, "10th_percentile": 7.77, "90th_percentile": 7.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.75, "10th_percentile": 14.75, "90th_percentile": 14.75, "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": 188.9, "maximum": 978.75, "setting": "outpatient", "gross_charge": 978.75, "discounted_cash": 685.12, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 978.75, "10th_percentile": 978.75, "90th_percentile": 978.75, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 978.75, "10th_percentile": 978.75, "90th_percentile": 978.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $978.75 @ 12.5% = $122.34 due to $0.00 Claim Price", "median_amount": 122.34, "10th_percentile": 122.34, "90th_percentile": 122.34, "count": "0", "methodology": "other", "additional_payer_notes": "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: $978.75 @ 12.5% = $122.34 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 467.84, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 467.84, "10th_percentile": 467.84, "90th_percentile": 467.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 467.84, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 467.84, "10th_percentile": 467.84, "90th_percentile": 467.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 467.84, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 467.84, "10th_percentile": 467.84, "90th_percentile": 467.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 349.22, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 349.22, "10th_percentile": 349.22, "90th_percentile": 349.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 349.22, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 349.22, "10th_percentile": 349.22, "90th_percentile": 349.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 331.8, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 331.8, "10th_percentile": 331.8, "90th_percentile": 331.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 331.8, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 331.8, "10th_percentile": 331.8, "90th_percentile": 331.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 520.7, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 520.7, "10th_percentile": 520.7, "90th_percentile": 520.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 513.84, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 513.84, "10th_percentile": 513.84, "90th_percentile": 513.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 188.9, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 188.9, "10th_percentile": 188.9, "90th_percentile": 188.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 336.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 336.69, "10th_percentile": 336.69, "90th_percentile": 336.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 347.46, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 347.46, "10th_percentile": 347.46, "90th_percentile": 347.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 734.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 734.06, "10th_percentile": 734.06, "90th_percentile": 734.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 489.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 489.38, "10th_percentile": 489.38, "90th_percentile": 489.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 978.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 978.75, "10th_percentile": 978.75, "90th_percentile": 978.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 297.05, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 297.05, "10th_percentile": 297.05, "90th_percentile": 297.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 714.49, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 714.49, "10th_percentile": 714.49, "90th_percentile": 714.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 685.13, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 685.13, "10th_percentile": 685.13, "90th_percentile": 685.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 783.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 783.0, "10th_percentile": 783.0, "90th_percentile": 783.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 978.75, "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 $978.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 978.75, "10th_percentile": 978.75, "90th_percentile": 978.75, "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 $978.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 616.61, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $616.61 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 616.61, "10th_percentile": 616.61, "90th_percentile": 616.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $616.61 so that total pmt for all claim lines does not exceed 63% of claim billed amount." } ] } ] }, { "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": "43598-0554-30", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR 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": "NWR BLUE CROSS MEDICARE ADVT", "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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "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": 0.92, "maximum": 4.75, "setting": "outpatient", "gross_charge": 4.75, "discounted_cash": 3.32, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1.69, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1.69, "10th_percentile": 1.69, "90th_percentile": 1.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 1.63, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% 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; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 2.49, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.49, "10th_percentile": 2.49, "90th_percentile": 2.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.92, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.92, "10th_percentile": 0.92, "90th_percentile": 0.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.94, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 2.5, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 1.44, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% 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; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 2.25, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 2.53, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 2.53, "10th_percentile": 2.53, "90th_percentile": 2.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 3.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 3.33, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 3.47, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 3.47, "10th_percentile": 3.47, "90th_percentile": 3.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 1.47, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 2.99, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2.99 so that total pmt for all claim lines does not exceed 63% 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": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2.99 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.69, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.69, "10th_percentile": 1.69, "90th_percentile": 1.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.69, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.69, "10th_percentile": 1.69, "90th_percentile": 1.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.33, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.33, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1.85, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1.85, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "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": "NWR 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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 2.31, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.31, "10th_percentile": 2.31, "90th_percentile": 2.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "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": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR BLUE CROSS MEDICARE ADVT", "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": "NWR 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "description": "ARIPIPRAZOLE LAUROXIL 441 MG/1.6 ML IM SERS", "drug_information": { "unit": 1.6, "type": "ML" }, "code_information": [ { "code": "RX-206283", "type": "CDM" }, { "code": "J1944", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "65757-0401-03", "type": "NDC" } ], "standard_charges": [ { "minimum": 1863.46, "maximum": 9655.25, "setting": "outpatient", "gross_charge": 9655.25, "discounted_cash": 6758.67, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9655.25, "10th_percentile": 9655.25, "90th_percentile": 9655.25, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9655.25, "10th_percentile": 9655.25, "90th_percentile": 9655.25, "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4615.21, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4615.21, "10th_percentile": 4615.21, "90th_percentile": 4615.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4615.21, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4615.21, "10th_percentile": 4615.21, "90th_percentile": 4615.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4615.21, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4615.21, "10th_percentile": 4615.21, "90th_percentile": 4615.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 3444.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3444.99, "10th_percentile": 3444.99, "90th_percentile": 3444.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 3444.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3444.99, "10th_percentile": 3444.99, "90th_percentile": 3444.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 3273.13, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3273.13, "10th_percentile": 3273.13, "90th_percentile": 3273.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 3273.13, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3273.13, "10th_percentile": 3273.13, "90th_percentile": 3273.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 3427.61, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 3427.61, "10th_percentile": 3427.61, "90th_percentile": 3427.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 3321.41, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 3321.41, "10th_percentile": 3321.41, "90th_percentile": 3321.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 5069.01, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5069.01, "10th_percentile": 5069.01, "90th_percentile": 5069.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 7724.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 7724.2, "10th_percentile": 7724.2, "90th_percentile": 7724.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 1863.46, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1863.46, "10th_percentile": 1863.46, "90th_percentile": 1863.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 9655.25, "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 $9,655.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 9655.25, "10th_percentile": 9655.25, "90th_percentile": 9655.25, "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 $9,655.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $9,655.25 @ 12.5% = $1,206.91 due to $0.00 Claim Price", "median_amount": 1206.91, "10th_percentile": 1206.91, "90th_percentile": 1206.91, "count": "0", "methodology": "other", "additional_payer_notes": "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: $9,655.25 @ 12.5% = $1,206.91 due to $0.00 Claim Price" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 5136.59, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 5136.59, "10th_percentile": 5136.59, "90th_percentile": 5136.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 7241.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 7241.44, "10th_percentile": 7241.44, "90th_percentile": 7241.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 4827.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 4827.63, "10th_percentile": 4827.63, "90th_percentile": 4827.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 9655.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9655.25, "10th_percentile": 9655.25, "90th_percentile": 9655.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 2930.37, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 2930.37, "10th_percentile": 2930.37, "90th_percentile": 2930.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 7048.33, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 7048.33, "10th_percentile": 7048.33, "90th_percentile": 7048.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 6758.68, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 6758.68, "10th_percentile": 6758.68, "90th_percentile": 6758.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 6082.81, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $6,082.81 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 6082.81, "10th_percentile": 6082.81, "90th_percentile": 6082.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $6,082.81 so that total pmt for all claim lines does not exceed 63% of claim billed amount." } ] } ] }, { "description": "ARISTA ABSORBABLE HEMOSTATIC PARTICLES 2 GRAMS", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-408805", "type": "CDM" }, { "code": "27100000", "type": "LOCAL" }, { "code": "0271", "type": "RC" }, { "code": "99991-0031-86", "type": "NDC" } ], "standard_charges": [ { "minimum": 175.24, "maximum": 908.0, "setting": "outpatient", "gross_charge": 908.0, "discounted_cash": 635.6, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 442.2, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 442.2, "10th_percentile": 442.2, "90th_percentile": 442.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 312.35, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 312.35, "10th_percentile": 312.35, "90th_percentile": 312.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 476.7, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 476.7, "10th_percentile": 476.7, "90th_percentile": 476.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 322.34, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 322.34, "10th_percentile": 322.34, "90th_percentile": 322.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 175.24, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 175.24, "10th_percentile": 175.24, "90th_percentile": 175.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 323.97, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 323.97, "10th_percentile": 323.97, "90th_percentile": 323.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 353.67, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 353.67, "10th_percentile": 353.67, "90th_percentile": 353.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 726.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 726.4, "10th_percentile": 726.4, "90th_percentile": 726.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 267.77, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 267.77, "10th_percentile": 267.77, "90th_percentile": 267.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 255.06, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 255.06, "10th_percentile": 255.06, "90th_percentile": 255.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 255.06, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 255.06, "10th_percentile": 255.06, "90th_percentile": 255.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 323.97, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 323.97, "10th_percentile": 323.97, "90th_percentile": 323.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 908.0, "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 $908.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 908.0, "10th_percentile": 908.0, "90th_percentile": 908.0, "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 $908.00 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": "NWR BCBS PPO", "standard_charge_dollar": 353.67, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 353.67, "10th_percentile": 353.67, "90th_percentile": 353.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 483.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 483.06, "10th_percentile": 483.06, "90th_percentile": 483.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 178.88, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 178.88, "10th_percentile": 178.88, "90th_percentile": 178.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 681.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 681.0, "10th_percentile": 681.0, "90th_percentile": 681.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 280.57, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 280.57, "10th_percentile": 280.57, "90th_percentile": 280.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 635.6, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 635.6, "10th_percentile": 635.6, "90th_percentile": 635.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 662.84, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 662.84, "10th_percentile": 662.84, "90th_percentile": 662.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 454.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 454.0, "10th_percentile": 454.0, "90th_percentile": 454.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 275.58, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 275.58, "10th_percentile": 275.58, "90th_percentile": 275.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 908.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 908.0, "10th_percentile": 908.0, "90th_percentile": 908.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 572.04, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $572.04 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 572.04, "10th_percentile": 572.04, "90th_percentile": 572.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $572.04 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 583.21, "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": 583.21, "10th_percentile": 583.21, "90th_percentile": 583.21, "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": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 430.39, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 430.39, "10th_percentile": 430.39, "90th_percentile": 430.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 478.52, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 478.52, "10th_percentile": 478.52, "90th_percentile": 478.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 908.0, "10th_percentile": 908.0, "90th_percentile": 908.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 908.0, "10th_percentile": 908.0, "90th_percentile": 908.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 908.0, "10th_percentile": 908.0, "90th_percentile": 908.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "ARMADA 35 OTW BALLOON 7.0 X 40MM X 80CM", "code_information": [ { "code": "SUP-137687", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 86.99, "maximum": 450.71, "setting": "outpatient", "gross_charge": 450.71, "discounted_cash": 315.5, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 160.0, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 160.0, "10th_percentile": 160.0, "90th_percentile": 160.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 236.62, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 236.62, "10th_percentile": 236.62, "90th_percentile": 236.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 219.5, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 219.5, "10th_percentile": 219.5, "90th_percentile": 219.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 86.99, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 86.99, "10th_percentile": 86.99, "90th_percentile": 86.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 155.04, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 155.04, "10th_percentile": 155.04, "90th_percentile": 155.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 215.44, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 215.44, "10th_percentile": 215.44, "90th_percentile": 215.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 215.44, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 215.44, "10th_percentile": 215.44, "90th_percentile": 215.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 215.44, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 215.44, "10th_percentile": 215.44, "90th_percentile": 215.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 160.81, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 160.81, "10th_percentile": 160.81, "90th_percentile": 160.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 160.81, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 160.81, "10th_percentile": 160.81, "90th_percentile": 160.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 152.79, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 152.79, "10th_percentile": 152.79, "90th_percentile": 152.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 152.79, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 152.79, "10th_percentile": 152.79, "90th_percentile": 152.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 329.02, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 329.02, "10th_percentile": 329.02, "90th_percentile": 329.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 139.27, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 97.08, "10th_percentile": 97.08, "90th_percentile": 97.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 88.79, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 88.79, "10th_percentile": 88.79, "90th_percentile": 88.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 225.36, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 225.36, "10th_percentile": 225.36, "90th_percentile": 225.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 237.52, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 237.52, "10th_percentile": 237.52, "90th_percentile": 237.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 360.57, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 360.57, "10th_percentile": 360.57, "90th_percentile": 360.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 315.5, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 315.5, "10th_percentile": 315.5, "90th_percentile": 315.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 239.78, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 239.78, "10th_percentile": 239.78, "90th_percentile": 239.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 450.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 450.71, "10th_percentile": 450.71, "90th_percentile": 450.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 338.03, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 338.03, "10th_percentile": 338.03, "90th_percentile": 338.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 136.79, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 136.79, "10th_percentile": 136.79, "90th_percentile": 136.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 213.64, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 213.64, "10th_percentile": 213.64, "90th_percentile": 213.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 289.49, "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": 289.49, "10th_percentile": 289.49, "90th_percentile": 289.49, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 450.71, "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 $450.71 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 450.71, "10th_percentile": 450.71, "90th_percentile": 450.71, "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 $450.71 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 283.95, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $283.95 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 283.95, "10th_percentile": 283.95, "90th_percentile": 283.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $283.95 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 450.71, "10th_percentile": 450.71, "90th_percentile": 450.71, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 450.71, "10th_percentile": 450.71, "90th_percentile": 450.71, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $450.71 @ 12.5% = $56.34 due to $0.00 Claim Price", "median_amount": 56.34, "10th_percentile": 56.34, "90th_percentile": 56.34, "count": "0", "methodology": "other", "additional_payer_notes": "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: $450.71 @ 12.5% = $56.34 due to $0.00 Claim Price" } ] } ] }, { "description": "ARROW GLENOID INSERT METAL BASE (SZ 44)", "code_information": [ { "code": "SUP-338168", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 124.27, "maximum": 643.88, "setting": "outpatient", "gross_charge": 643.88, "discounted_cash": 450.72, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 124.27, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1001.28, "10th_percentile": 1001.28, "90th_percentile": 1001.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 198.96, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.6, "10th_percentile": 1188.6, "90th_percentile": 1188.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 307.77, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 307.77, "10th_percentile": 307.77, "90th_percentile": 307.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 307.77, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 307.77, "10th_percentile": 307.77, "90th_percentile": 307.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 307.77, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 307.77, "10th_percentile": 307.77, "90th_percentile": 307.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 229.74, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 229.74, "10th_percentile": 229.74, "90th_percentile": 229.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 229.74, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 229.74, "10th_percentile": 229.74, "90th_percentile": 229.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 218.28, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 218.28, "10th_percentile": 218.28, "90th_percentile": 218.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 218.28, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 218.28, "10th_percentile": 218.28, "90th_percentile": 218.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 188.01, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 188.01, "10th_percentile": 188.01, "90th_percentile": 188.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 188.01, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 188.01, "10th_percentile": 188.01, "90th_percentile": 188.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 339.32, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2627.73, "10th_percentile": 2627.73, "90th_percentile": 2627.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 643.88, "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 $643.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 643.88, "10th_percentile": 643.88, "90th_percentile": 643.88, "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 $643.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 405.64, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $405.64 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 405.64, "10th_percentile": 405.64, "90th_percentile": 405.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $405.64 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 413.56, "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": 413.56, "10th_percentile": 413.56, "90th_percentile": 413.56, "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": "NWR UHC CORE", "standard_charge_dollar": 305.2, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 305.2, "10th_percentile": 305.2, "90th_percentile": 305.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 450.72, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 450.72, "10th_percentile": 450.72, "90th_percentile": 450.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 342.54, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 342.54, "10th_percentile": 342.54, "90th_percentile": 342.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 515.1, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 515.1, "10th_percentile": 515.1, "90th_percentile": 515.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 126.84, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 126.84, "10th_percentile": 126.84, "90th_percentile": 126.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 228.58, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 228.58, "10th_percentile": 228.58, "90th_percentile": 228.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 482.91, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 482.91, "10th_percentile": 482.91, "90th_percentile": 482.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 221.49, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 221.49, "10th_percentile": 221.49, "90th_percentile": 221.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 643.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 643.88, "10th_percentile": 643.88, "90th_percentile": 643.88, "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": "NWR HFN PPO", "standard_charge_dollar": 470.03, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 470.03, "10th_percentile": 470.03, "90th_percentile": 470.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 195.42, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 195.42, "10th_percentile": 195.42, "90th_percentile": 195.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 321.94, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 321.94, "10th_percentile": 321.94, "90th_percentile": 321.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 643.88, "10th_percentile": 643.88, "90th_percentile": 643.88, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 643.88, "10th_percentile": 643.88, "90th_percentile": 643.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $643.88 @ 12.5% = $80.49 due to $0.00 Claim Price", "median_amount": 80.49, "10th_percentile": 80.49, "90th_percentile": 80.49, "count": "0", "methodology": "other", "additional_payer_notes": "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: $643.88 @ 12.5% = $80.49 due to $0.00 Claim Price" } ] } ] }, { "description": "ARTERIAL LINE TRANSDUCER SINGLE", "code_information": [ { "code": "SUP-303387", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 9.54, "maximum": 49.45, "setting": "outpatient", "gross_charge": 49.45, "discounted_cash": 34.61, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 49.45, "10th_percentile": 49.45, "90th_percentile": 49.45, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 49.45, "10th_percentile": 49.45, "90th_percentile": 49.45, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 49.45, "10th_percentile": 49.45, "90th_percentile": 49.45, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 13.89, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 13.89, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 17.64, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.64, "10th_percentile": 17.64, "90th_percentile": 17.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 17.64, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.64, "10th_percentile": 17.64, "90th_percentile": 17.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 19.26, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.26, "10th_percentile": 19.26, "90th_percentile": 19.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 19.26, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.26, "10th_percentile": 19.26, "90th_percentile": 19.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 17.55, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 17.55, "10th_percentile": 17.55, "90th_percentile": 17.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 25.96, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.96, "10th_percentile": 25.96, "90th_percentile": 25.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 17.01, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 17.01, "10th_percentile": 17.01, "90th_percentile": 17.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 24.08, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.08, "10th_percentile": 24.08, "90th_percentile": 24.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 9.54, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 9.54, "10th_percentile": 9.54, "90th_percentile": 9.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 37.09, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 37.09, "10th_percentile": 37.09, "90th_percentile": 37.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 14.58, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.58, "10th_percentile": 14.58, "90th_percentile": 14.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 26.31, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 26.31, "10th_percentile": 26.31, "90th_percentile": 26.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 49.45, "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 $49.45 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 49.45, "10th_percentile": 49.45, "90th_percentile": 49.45, "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 $49.45 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 9.74, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.74, "10th_percentile": 9.74, "90th_percentile": 9.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 39.56, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 39.56, "10th_percentile": 39.56, "90th_percentile": 39.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 15.28, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.28, "10th_percentile": 15.28, "90th_percentile": 15.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 34.62, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 34.62, "10th_percentile": 34.62, "90th_percentile": 34.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 49.45, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 49.45, "10th_percentile": 49.45, "90th_percentile": 49.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 24.73, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 24.73, "10th_percentile": 24.73, "90th_percentile": 24.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 36.1, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 36.1, "10th_percentile": 36.1, "90th_percentile": 36.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 26.06, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.06, "10th_percentile": 26.06, "90th_percentile": 26.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 15.01, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 15.01, "10th_percentile": 15.01, "90th_percentile": 15.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 31.15, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $31.15 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 31.15, "10th_percentile": 31.15, "90th_percentile": 31.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $31.15 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 31.76, "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": 31.76, "10th_percentile": 31.76, "90th_percentile": 31.76, "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": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 23.44, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 23.44, "10th_percentile": 23.44, "90th_percentile": 23.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "description": "ARTERIAL WRIST SUPPORT ADULT (29980)", "code_information": [ { "code": "SUP-601", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 3.9, "maximum": 20.22, "setting": "outpatient", "gross_charge": 20.22, "discounted_cash": 14.15, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20.22, "10th_percentile": 20.22, "90th_percentile": 20.22, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20.22, "10th_percentile": 20.22, "90th_percentile": 20.22, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20.22, "10th_percentile": 20.22, "90th_percentile": 20.22, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5.68, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.68, "10th_percentile": 5.68, "90th_percentile": 5.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5.68, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.68, "10th_percentile": 5.68, "90th_percentile": 5.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 7.21, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.21, "10th_percentile": 7.21, "90th_percentile": 7.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 7.21, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.21, "10th_percentile": 7.21, "90th_percentile": 7.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 7.88, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.88, "10th_percentile": 7.88, "90th_percentile": 7.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 7.88, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.88, "10th_percentile": 7.88, "90th_percentile": 7.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 7.18, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% 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; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 10.62, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.62, "10th_percentile": 10.62, "90th_percentile": 10.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 6.96, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 6.96, "10th_percentile": 6.96, "90th_percentile": 6.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 9.85, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.85, "10th_percentile": 9.85, "90th_percentile": 9.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 3.9, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 3.9, "10th_percentile": 3.9, "90th_percentile": 3.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 12.99, "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": 12.99, "10th_percentile": 12.99, "90th_percentile": 12.99, "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": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 15.17, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 15.17, "10th_percentile": 15.17, "90th_percentile": 15.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5.96, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.96, "10th_percentile": 5.96, "90th_percentile": 5.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 6.14, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 6.14, "10th_percentile": 6.14, "90th_percentile": 6.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 9.58, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 9.58, "10th_percentile": 9.58, "90th_percentile": 9.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 14.76, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 14.76, "10th_percentile": 14.76, "90th_percentile": 14.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 10.76, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 10.76, "10th_percentile": 10.76, "90th_percentile": 10.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 12.74, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $12.74 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 12.74, "10th_percentile": 12.74, "90th_percentile": 12.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $12.74 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 20.22, "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 $20.22 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 20.22, "10th_percentile": 20.22, "90th_percentile": 20.22, "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 $20.22 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 20.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 20.22, "10th_percentile": 20.22, "90th_percentile": 20.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 3.98, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.98, "10th_percentile": 3.98, "90th_percentile": 3.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 10.66, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.66, "10th_percentile": 10.66, "90th_percentile": 10.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 10.11, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 10.11, "10th_percentile": 10.11, "90th_percentile": 10.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 16.18, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 16.18, "10th_percentile": 16.18, "90th_percentile": 16.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 6.25, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.25, "10th_percentile": 6.25, "90th_percentile": 6.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 14.15, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 14.15, "10th_percentile": 14.15, "90th_percentile": 14.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" } ] } ] }, { "description": "ARTHREX INSERTER BUTTON STERILE AR-2262", "code_information": [ { "code": "SUP-128196", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 115.98, "maximum": 600.95, "setting": "outpatient", "gross_charge": 600.95, "discounted_cash": 420.66, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 600.95, "10th_percentile": 600.95, "90th_percentile": 600.95, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 600.95, "10th_percentile": 600.95, "90th_percentile": 600.95, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 600.95, "10th_percentile": 600.95, "90th_percentile": 600.95, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 168.81, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 168.81, "10th_percentile": 168.81, "90th_percentile": 168.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 168.81, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 168.81, "10th_percentile": 168.81, "90th_percentile": 168.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 214.42, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 214.42, "10th_percentile": 214.42, "90th_percentile": 214.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 214.42, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 214.42, "10th_percentile": 214.42, "90th_percentile": 214.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 234.07, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 234.07, "10th_percentile": 234.07, "90th_percentile": 234.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 234.07, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 234.07, "10th_percentile": 234.07, "90th_percentile": 234.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 213.34, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 213.34, "10th_percentile": 213.34, "90th_percentile": 213.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 315.5, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 315.5, "10th_percentile": 315.5, "90th_percentile": 315.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 206.73, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 206.73, "10th_percentile": 206.73, "90th_percentile": 206.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 292.66, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 292.66, "10th_percentile": 292.66, "90th_percentile": 292.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 115.98, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 115.98, "10th_percentile": 115.98, "90th_percentile": 115.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 385.99, "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": 385.99, "10th_percentile": 385.99, "90th_percentile": 385.99, "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": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 450.71, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 450.71, "10th_percentile": 450.71, "90th_percentile": 450.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 177.22, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 177.22, "10th_percentile": 177.22, "90th_percentile": 177.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 182.39, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 182.39, "10th_percentile": 182.39, "90th_percentile": 182.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 284.85, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 284.85, "10th_percentile": 284.85, "90th_percentile": 284.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 438.69, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 438.69, "10th_percentile": 438.69, "90th_percentile": 438.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 319.71, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 319.71, "10th_percentile": 319.71, "90th_percentile": 319.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 378.6, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $378.60 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 378.6, "10th_percentile": 378.6, "90th_percentile": 378.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $378.60 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 600.95, "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 $600.95 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 600.95, "10th_percentile": 600.95, "90th_percentile": 600.95, "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 $600.95 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 600.95, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 600.95, "10th_percentile": 600.95, "90th_percentile": 600.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 118.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 118.39, "10th_percentile": 118.39, "90th_percentile": 118.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 316.7, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 316.7, "10th_percentile": 316.7, "90th_percentile": 316.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 300.48, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 300.48, "10th_percentile": 300.48, "90th_percentile": 300.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 480.76, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 480.76, "10th_percentile": 480.76, "90th_percentile": 480.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 185.69, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 185.69, "10th_percentile": 185.69, "90th_percentile": 185.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 420.67, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 420.67, "10th_percentile": 420.67, "90th_percentile": 420.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% 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": 26.51, "maximum": 137.36, "setting": "outpatient", "gross_charge": 137.36, "discounted_cash": 96.15, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.36, "10th_percentile": 137.36, "90th_percentile": 137.36, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.36, "10th_percentile": 137.36, "90th_percentile": 137.36, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 137.36, "10th_percentile": 137.36, "90th_percentile": 137.36, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 53.5, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.5, "10th_percentile": 53.5, "90th_percentile": 53.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 53.5, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.5, "10th_percentile": 53.5, "90th_percentile": 53.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 49.01, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 49.01, "10th_percentile": 49.01, "90th_percentile": 49.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 49.01, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 49.01, "10th_percentile": 49.01, "90th_percentile": 49.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 38.58, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.58, "10th_percentile": 38.58, "90th_percentile": 38.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 38.58, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.58, "10th_percentile": 38.58, "90th_percentile": 38.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 66.89, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 66.89, "10th_percentile": 66.89, "90th_percentile": 66.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 26.51, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 26.51, "10th_percentile": 26.51, "90th_percentile": 26.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 72.11, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.11, "10th_percentile": 72.11, "90th_percentile": 72.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 48.76, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 48.76, "10th_percentile": 48.76, "90th_percentile": 48.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 47.25, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 47.25, "10th_percentile": 47.25, "90th_percentile": 47.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 73.08, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 73.08, "10th_percentile": 73.08, "90th_percentile": 73.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 65.11, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 65.11, "10th_percentile": 65.11, "90th_percentile": 65.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 41.69, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 41.69, "10th_percentile": 41.69, "90th_percentile": 41.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 88.23, "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": 88.23, "10th_percentile": 88.23, "90th_percentile": 88.23, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 27.06, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.06, "10th_percentile": 27.06, "90th_percentile": 27.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 109.89, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 109.89, "10th_percentile": 109.89, "90th_percentile": 109.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 72.39, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.39, "10th_percentile": 72.39, "90th_percentile": 72.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 137.36, "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 $137.36 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 137.36, "10th_percentile": 137.36, "90th_percentile": 137.36, "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 $137.36 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 86.54, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $86.54 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 86.54, "10th_percentile": 86.54, "90th_percentile": 86.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $86.54 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 40.51, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40.51, "10th_percentile": 40.51, "90th_percentile": 40.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 103.02, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 103.02, "10th_percentile": 103.02, "90th_percentile": 103.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 96.15, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 96.15, "10th_percentile": 96.15, "90th_percentile": 96.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 100.27, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 100.27, "10th_percentile": 100.27, "90th_percentile": 100.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 42.44, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.44, "10th_percentile": 42.44, "90th_percentile": 42.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 137.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 137.36, "10th_percentile": 137.36, "90th_percentile": 137.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 68.68, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 68.68, "10th_percentile": 68.68, "90th_percentile": 68.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% 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": 243.16, "maximum": 1259.89, "setting": "outpatient", "gross_charge": 1259.89, "discounted_cash": 881.92, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1259.89, "10th_percentile": 1259.89, "90th_percentile": 1259.89, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1259.89, "10th_percentile": 1259.89, "90th_percentile": 1259.89, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1259.89, "10th_percentile": 1259.89, "90th_percentile": 1259.89, "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": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 353.9, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 353.9, "10th_percentile": 353.9, "90th_percentile": 353.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 353.9, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 353.9, "10th_percentile": 353.9, "90th_percentile": 353.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 490.73, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 490.73, "10th_percentile": 490.73, "90th_percentile": 490.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 490.73, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 490.73, "10th_percentile": 490.73, "90th_percentile": 490.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 449.53, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 449.53, "10th_percentile": 449.53, "90th_percentile": 449.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 449.53, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 449.53, "10th_percentile": 449.53, "90th_percentile": 449.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 447.26, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 447.26, "10th_percentile": 447.26, "90th_percentile": 447.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 433.4, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 433.4, "10th_percentile": 433.4, "90th_percentile": 433.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 613.57, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 613.57, "10th_percentile": 613.57, "90th_percentile": 613.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 243.16, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 243.16, "10th_percentile": 243.16, "90th_percentile": 243.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 661.44, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 661.44, "10th_percentile": 661.44, "90th_percentile": 661.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1259.89, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1259.89, "10th_percentile": 1259.89, "90th_percentile": 1259.89, "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 371.54, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 371.54, "10th_percentile": 371.54, "90th_percentile": 371.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 629.95, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 629.95, "10th_percentile": 629.95, "90th_percentile": 629.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 881.92, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 881.92, "10th_percentile": 881.92, "90th_percentile": 881.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 919.72, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 919.72, "10th_percentile": 919.72, "90th_percentile": 919.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 663.96, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 663.96, "10th_percentile": 663.96, "90th_percentile": 663.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 382.38, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 382.38, "10th_percentile": 382.38, "90th_percentile": 382.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 793.73, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $793.73 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 793.73, "10th_percentile": 793.73, "90th_percentile": 793.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $793.73 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1259.89, "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 $1,259.89 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1259.89, "10th_percentile": 1259.89, "90th_percentile": 1259.89, "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 $1,259.89 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 248.2, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 248.2, "10th_percentile": 248.2, "90th_percentile": 248.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 1007.91, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1007.91, "10th_percentile": 1007.91, "90th_percentile": 1007.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 389.31, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 389.31, "10th_percentile": 389.31, "90th_percentile": 389.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 944.92, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 944.92, "10th_percentile": 944.92, "90th_percentile": 944.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 670.26, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 670.26, "10th_percentile": 670.26, "90th_percentile": 670.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 809.23, "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": 809.23, "10th_percentile": 809.23, "90th_percentile": 809.23, "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": "NWR UHC CORE", "standard_charge_dollar": 597.19, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 597.19, "10th_percentile": 597.19, "90th_percentile": 597.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "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": 538.5, "maximum": 2790.13, "setting": "outpatient", "gross_charge": 2790.13, "discounted_cash": 1953.09, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 862.15, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.6, "10th_percentile": 1188.6, "90th_percentile": 1188.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1333.68, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1333.68, "10th_percentile": 1333.68, "90th_percentile": 1333.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1333.68, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1333.68, "10th_percentile": 1333.68, "90th_percentile": 1333.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1333.68, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1333.68, "10th_percentile": 1333.68, "90th_percentile": 1333.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 995.52, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 995.52, "10th_percentile": 995.52, "90th_percentile": 995.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 945.85, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 945.85, "10th_percentile": 945.85, "90th_percentile": 945.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1470.4, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2627.73, "10th_percentile": 2627.73, "90th_percentile": 2627.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1484.35, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1484.35, "10th_percentile": 1484.35, "90th_percentile": 1484.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2790.13, "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 $2,790.13 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2790.13, "10th_percentile": 2790.13, "90th_percentile": 2790.13, "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 $2,790.13 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1757.78, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,757.78 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1757.78, "10th_percentile": 1757.78, "90th_percentile": 1757.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,757.78 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 549.66, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 549.66, "10th_percentile": 549.66, "90th_percentile": 549.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 2790.13, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2790.13, "10th_percentile": 2790.13, "90th_percentile": 2790.13, "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": "NWR HFN PPO", "standard_charge_dollar": 2036.79, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 2036.79, "10th_percentile": 2036.79, "90th_percentile": 2036.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2092.6, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 2092.6, "10th_percentile": 2092.6, "90th_percentile": 2092.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 1792.1, "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": 1792.1, "10th_percentile": 1792.1, "90th_percentile": 1792.1, "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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1953.09, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1953.09, "10th_percentile": 1953.09, "90th_percentile": 1953.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 846.8, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 846.8, "10th_percentile": 846.8, "90th_percentile": 846.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 2232.1, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2232.1, "10th_percentile": 2232.1, "90th_percentile": 2232.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 1322.52, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1322.52, "10th_percentile": 1322.52, "90th_percentile": 1322.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1395.07, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1395.07, "10th_percentile": 1395.07, "90th_percentile": 1395.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $2,790.13 @ 12.5% = $348.77 due to $0.00 Claim Price", "median_amount": 348.77, "10th_percentile": 348.77, "90th_percentile": 348.77, "count": "0", "methodology": "other", "additional_payer_notes": "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: $2,790.13 @ 12.5% = $348.77 due to $0.00 Claim Price" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 538.5, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1001.28, "10th_percentile": 1001.28, "90th_percentile": 1001.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 945.85, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 945.85, "10th_percentile": 945.85, "90th_percentile": 945.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 995.52, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 995.52, "10th_percentile": 995.52, "90th_percentile": 995.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 814.72, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 814.72, "10th_percentile": 814.72, "90th_percentile": 814.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 814.72, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 814.72, "10th_percentile": 814.72, "90th_percentile": 814.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 959.8, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 959.8, "10th_percentile": 959.8, "90th_percentile": 959.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 990.5, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 990.5, "10th_percentile": 990.5, "90th_percentile": 990.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2790.13, "10th_percentile": 2790.13, "90th_percentile": 2790.13, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2790.13, "10th_percentile": 2790.13, "90th_percentile": 2790.13, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR 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": "NWR BLUE CROSS MEDICARE ADVT", "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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ASENAPINE MALEATE 5 MG SL SUBL", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-180297", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "59762-2012-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.49, "maximum": 23.25, "setting": "outpatient", "gross_charge": 23.25, "discounted_cash": 16.27, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 23.25, "10th_percentile": 23.25, "90th_percentile": 23.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 23.25, "10th_percentile": 23.25, "90th_percentile": 23.25, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 23.25, "10th_percentile": 23.25, "90th_percentile": 23.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 12.21, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.21, "10th_percentile": 12.21, "90th_percentile": 12.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 8.0, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% 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; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 8.25, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 8.25, "10th_percentile": 8.25, "90th_percentile": 8.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 11.32, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.32, "10th_percentile": 11.32, "90th_percentile": 11.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 4.49, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 4.49, "10th_percentile": 4.49, "90th_percentile": 4.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 12.37, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 12.37, "10th_percentile": 12.37, "90th_percentile": 12.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 11.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 11.63, "10th_percentile": 11.63, "90th_percentile": 11.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 17.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 17.44, "10th_percentile": 17.44, "90th_percentile": 17.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 18.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 18.6, "10th_percentile": 18.6, "90th_percentile": 18.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 4.58, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.58, "10th_percentile": 4.58, "90th_percentile": 4.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 6.86, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.86, "10th_percentile": 6.86, "90th_percentile": 6.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 7.18, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 16.28, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 16.28, "10th_percentile": 16.28, "90th_percentile": 16.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 16.97, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 16.97, "10th_percentile": 16.97, "90th_percentile": 16.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 23.25, "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 $23.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 23.25, "10th_percentile": 23.25, "90th_percentile": 23.25, "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 $23.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 9.06, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.06, "10th_percentile": 9.06, "90th_percentile": 9.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 9.06, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.06, "10th_percentile": 9.06, "90th_percentile": 9.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 6.53, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.53, "10th_percentile": 6.53, "90th_percentile": 6.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 6.53, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.53, "10th_percentile": 6.53, "90th_percentile": 6.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 8.3, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.3, "10th_percentile": 8.3, "90th_percentile": 8.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 8.3, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.3, "10th_percentile": 8.3, "90th_percentile": 8.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 14.65, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $14.65 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 14.65, "10th_percentile": 14.65, "90th_percentile": 14.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $14.65 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 14.93, "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": 14.93, "10th_percentile": 14.93, "90th_percentile": 14.93, "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": "NWR UHC HMO/PPO", "standard_charge_dollar": 12.25, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC CORE", "standard_charge_dollar": 11.02, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 11.02, "10th_percentile": 11.02, "90th_percentile": 11.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 23.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 23.25, "10th_percentile": 23.25, "90th_percentile": 23.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 7.06, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 7.06, "10th_percentile": 7.06, "90th_percentile": 7.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" } ] } ] }, { "description": "ASPIRIN 81 MG ORAL TBEC", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-14113", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00904-6783-70", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR 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": "NWR BLUE CROSS MEDICARE ADVT", "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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ASPIRIN 325 MG ORAL TBEC", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-13654", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "69618-0015-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR BLUE CROSS MEDICARE ADVT", "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": "NWR 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "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": "51079-0759-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $2.00 @ 12.5% = $0.25 due to $0.00 Claim Price", "median_amount": 0.25, "10th_percentile": 0.25, "90th_percentile": 0.25, "count": "0", "methodology": "other", "additional_payer_notes": "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: $2.00 @ 12.5% = $0.25 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR BLUE CROSS MEDICARE ADVT", "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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $2.00 @ 12.5% = $0.25 due to $0.00 Claim Price", "median_amount": 0.25, "10th_percentile": 0.25, "90th_percentile": 0.25, "count": "0", "methodology": "other", "additional_payer_notes": "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: $2.00 @ 12.5% = $0.25 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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": "NWR BCBS PPO", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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" } ] } ] }, { "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": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $2.00 @ 12.5% = $0.25 due to $0.00 Claim Price", "median_amount": 0.25, "10th_percentile": 0.25, "90th_percentile": 0.25, "count": "0", "methodology": "other", "additional_payer_notes": "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: $2.00 @ 12.5% = $0.25 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.96, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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 [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" } ] } ] }, { "description": "ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) IV SOLN", "drug_information": { "unit": 14.0, "type": "ML" }, "code_information": [ { "code": "RX-221505", "type": "CDM" }, { "code": "J9022", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "50242-0918-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 10571.53, "maximum": 54774.75, "setting": "outpatient", "gross_charge": 54774.75, "discounted_cash": 38342.32, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 54774.75, "10th_percentile": 54774.75, "90th_percentile": 54774.75, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 54774.75, "10th_percentile": 54774.75, "90th_percentile": 54774.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $54,774.75 @ 12.5% = $6,846.84 due to $0.00 Claim Price", "median_amount": 6846.84, "10th_percentile": 6846.84, "90th_percentile": 6846.84, "count": "0", "methodology": "other", "additional_payer_notes": "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: $54,774.75 @ 12.5% = $6,846.84 due to $0.00 Claim Price" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 34508.09, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $34,508.09 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 34508.09, "10th_percentile": 34508.09, "90th_percentile": 34508.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $34,508.09 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 54774.75, "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 $54,774.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 54774.75, "10th_percentile": 54774.75, "90th_percentile": 54774.75, "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 $54,774.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 10571.53, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 10571.53, "10th_percentile": 10571.53, "90th_percentile": 10571.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 18842.51, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 18842.51, "10th_percentile": 18842.51, "90th_percentile": 18842.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 54774.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 54774.75, "10th_percentile": 54774.75, "90th_percentile": 54774.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 29140.17, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 29140.17, "10th_percentile": 29140.17, "90th_percentile": 29140.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 43819.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 43819.8, "10th_percentile": 43819.8, "90th_percentile": 43819.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 19445.04, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 19445.04, "10th_percentile": 19445.04, "90th_percentile": 19445.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 41081.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 41081.06, "10th_percentile": 41081.06, "90th_percentile": 41081.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 27387.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 27387.38, "10th_percentile": 27387.38, "90th_percentile": 27387.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 39985.57, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 39985.57, "10th_percentile": 39985.57, "90th_percentile": 39985.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 16624.14, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 16624.14, "10th_percentile": 16624.14, "90th_percentile": 16624.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 38342.33, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 38342.33, "10th_percentile": 38342.33, "90th_percentile": 38342.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 28756.74, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28756.74, "10th_percentile": 28756.74, "90th_percentile": 28756.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 18568.64, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18568.64, "10th_percentile": 18568.64, "90th_percentile": 18568.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 18568.64, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18568.64, "10th_percentile": 18568.64, "90th_percentile": 18568.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 19543.63, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19543.63, "10th_percentile": 19543.63, "90th_percentile": 19543.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 19543.63, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19543.63, "10th_percentile": 19543.63, "90th_percentile": 19543.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 26182.33, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26182.33, "10th_percentile": 26182.33, "90th_percentile": 26182.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 26182.33, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26182.33, "10th_percentile": 26182.33, "90th_percentile": 26182.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 26182.33, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26182.33, "10th_percentile": 26182.33, "90th_percentile": 26182.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ATHEROSCLEROSIS WITHOUT MCC", "code_information": [ { "code": "303", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 4790.38, "maximum": 8230.54, "setting": "inpatient", "gross_charge": 47698.5, "discounted_cash": 33388.95, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 8230.54, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 8230.54, "10th_percentile": 8230.54, "90th_percentile": 8230.54, "count": "11", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 5279.23, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 5279.23, "10th_percentile": 5279.23, "90th_percentile": 5279.23, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5384.93, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 7,999.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 5983.17, "10th_percentile": 5983.17, "90th_percentile": 5983.17, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 5279.23, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 5279.23, "10th_percentile": 5279.23, "90th_percentile": 5279.23, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5491.29, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 8,157.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 6091.64, "10th_percentile": 6091.64, "90th_percentile": 6091.64, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5279.23, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 7,842.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 5868.68, "10th_percentile": 5868.68, "90th_percentile": 5868.68, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 8230.54, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 12,226.00, and; Pricing Extension - NM HB XR PRC - NWR 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": 8230.54, "10th_percentile": 8230.54, "90th_percentile": 8230.54, "count": "11", "methodology": "case rate" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_percentage": 19.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 8964.69, "10th_percentile": 8964.69, "90th_percentile": 8964.69, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; 80% Billed", "median_amount": 37159.2, "10th_percentile": 37159.2, "90th_percentile": 37159.2, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Stop Loss; 70% Billed", "median_amount": 32514.3, "10th_percentile": 32514.3, "90th_percentile": 32514.3, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_percentage": 73.0, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All Inpatient Services; 73% Billed", "median_amount": 33907.77, "10th_percentile": 33907.77, "90th_percentile": 33907.77, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_percentage": 50.8, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; 50.8% Billed", "median_amount": 23596.09, "10th_percentile": 23596.09, "90th_percentile": 23596.09, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient Services; 50% Billed", "median_amount": 23224.5, "10th_percentile": 23224.5, "90th_percentile": 23224.5, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 71.3, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; IP Services. ADP RATE (for patient estimates only); 71.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33118.14, "10th_percentile": 33118.14, "90th_percentile": 33118.14, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; 30.35% Billed", "median_amount": 14097.27, "10th_percentile": 14097.27, "90th_percentile": 14097.27, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; 100% Billed", "median_amount": 46449.0, "10th_percentile": 46449.0, "90th_percentile": 46449.0, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 34836.75, "10th_percentile": 34836.75, "90th_percentile": 34836.75, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 7322.4, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 63% of charges. Total pmt for all lines paid so far is less than 63% of claim billed amount.", "median_amount": 7322.4, "10th_percentile": 7322.4, "90th_percentile": 7322.4, "count": "11", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; DRG Base Rate; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 10,877.00, and; Pricing Extension - NM HB XR PRC - NWR PHCS REV CODE ADD ONTO DRG PRICING & LES*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 63% of charges. Total pmt for all lines paid so far is less than 63% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_dollar": 4790.38, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; 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: $6,012.54; Total: $6,012.54", "median_amount": 6012.54, "10th_percentile": 6012.54, "90th_percentile": 6012.54, "count": "11", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; 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: $6,012.54; Total: $6,012.54" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_dollar": 4790.38, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.67, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $5,671.98; Total: $5,671.98 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5671.98, "10th_percentile": 5671.98, "90th_percentile": 5671.98, "count": "11", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.67, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $5,671.98; Total: $5,671.98 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_dollar": 4790.38, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.67, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $5,671.98; Total: $5,671.98 Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5671.98, "10th_percentile": 5671.98, "90th_percentile": 5671.98, "count": "11", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.67, and; Pricing Extension - NM HB XR PRC - MEDICARE IP DRG CALC EXCL O-IME & LESSOR OF; Note: Multiple pricing methods applied. Base payment: $5,671.98; Total: $5,671.98 Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_percentage": 34.5, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; 34.5% Billed", "median_amount": 16024.91, "10th_percentile": 16024.91, "90th_percentile": 16024.91, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_percentage": 36.1, "standard_charge_algorithm": "Re-evaluated: HLB.796049288; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; 36.1% Billed", "median_amount": 16768.09, "10th_percentile": 16768.09, "90th_percentile": 16768.09, "count": "11", "methodology": "percent of total billed charges" } ] } ] }, { "description": "ATL STAPLE CAUDAL TI", "code_information": [ { "code": "SUP-306208", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 314.81, "maximum": 1631.15, "setting": "outpatient", "gross_charge": 1631.15, "discounted_cash": 1141.8, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 314.81, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 447.84, "10th_percentile": 447.84, "90th_percentile": 447.84, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 859.62, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 825.02, "10th_percentile": 825.02, "90th_percentile": 825.02, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 504.03, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 448.23, "10th_percentile": 448.23, "90th_percentile": 448.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,631.15 @ 12.5% = $203.89 due to $0.00 Claim Price", "median_amount": 203.89, "10th_percentile": 203.89, "90th_percentile": 203.89, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,631.15 @ 12.5% = $203.89 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 476.3, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 476.3, "10th_percentile": 476.3, "90th_percentile": 476.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 476.3, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 476.3, "10th_percentile": 476.3, "90th_percentile": 476.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 552.96, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 552.96, "10th_percentile": 552.96, "90th_percentile": 552.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 552.96, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 552.96, "10th_percentile": 552.96, "90th_percentile": 552.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 581.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 581.99, "10th_percentile": 581.99, "90th_percentile": 581.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 581.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 581.99, "10th_percentile": 581.99, "90th_percentile": 581.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1141.81, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1141.81, "10th_percentile": 1141.81, "90th_percentile": 1141.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 815.58, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 815.58, "10th_percentile": 815.58, "90th_percentile": 815.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 579.06, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 579.06, "10th_percentile": 579.06, "90th_percentile": 579.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1223.36, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1223.36, "10th_percentile": 1223.36, "90th_percentile": 1223.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1190.74, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1190.74, "10th_percentile": 1190.74, "90th_percentile": 1190.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 867.77, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 867.77, "10th_percentile": 867.77, "90th_percentile": 867.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1304.92, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1304.92, "10th_percentile": 1304.92, "90th_percentile": 1304.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1027.62, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,027.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1027.62, "10th_percentile": 1027.62, "90th_percentile": 1027.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,027.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1631.15, "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 $1,631.15 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "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 $1,631.15 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 495.05, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 495.05, "10th_percentile": 495.05, "90th_percentile": 495.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 561.12, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 561.12, "10th_percentile": 561.12, "90th_percentile": 561.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 773.17, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 773.17, "10th_percentile": 773.17, "90th_percentile": 773.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 321.34, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 321.34, "10th_percentile": 321.34, "90th_percentile": 321.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 1047.69, "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": 1047.69, "10th_percentile": 1047.69, "90th_percentile": 1047.69, "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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1631.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ATOMOXETINE 25 MG ORAL CAP", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-34446", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00093-3544-56", "type": "NDC" } ], "standard_charges": [ { "minimum": 4.49, "maximum": 23.25, "setting": "outpatient", "gross_charge": 23.25, "discounted_cash": 16.27, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 23.25, "10th_percentile": 23.25, "90th_percentile": 23.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 23.25, "10th_percentile": 23.25, "90th_percentile": 23.25, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 23.25, "10th_percentile": 23.25, "90th_percentile": 23.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 12.21, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.21, "10th_percentile": 12.21, "90th_percentile": 12.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 8.0, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% 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; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 8.25, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 8.25, "10th_percentile": 8.25, "90th_percentile": 8.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 4.49, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 4.49, "10th_percentile": 4.49, "90th_percentile": 4.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 12.37, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 12.37, "10th_percentile": 12.37, "90th_percentile": 12.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 11.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 11.63, "10th_percentile": 11.63, "90th_percentile": 11.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 17.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 17.44, "10th_percentile": 17.44, "90th_percentile": 17.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 12.25, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 18.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 18.6, "10th_percentile": 18.6, "90th_percentile": 18.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 7.06, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 7.06, "10th_percentile": 7.06, "90th_percentile": 7.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 4.58, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.58, "10th_percentile": 4.58, "90th_percentile": 4.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 6.86, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.86, "10th_percentile": 6.86, "90th_percentile": 6.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC CORE", "standard_charge_dollar": 11.02, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 11.02, "10th_percentile": 11.02, "90th_percentile": 11.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 7.18, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 14.93, "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": 14.93, "10th_percentile": 14.93, "90th_percentile": 14.93, "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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 16.28, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 16.28, "10th_percentile": 16.28, "90th_percentile": 16.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 16.97, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 16.97, "10th_percentile": 16.97, "90th_percentile": 16.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 23.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 23.25, "10th_percentile": 23.25, "90th_percentile": 23.25, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 23.25, "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 $23.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 23.25, "10th_percentile": 23.25, "90th_percentile": 23.25, "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 $23.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 14.65, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $14.65 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 14.65, "10th_percentile": 14.65, "90th_percentile": 14.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $14.65 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 9.06, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.06, "10th_percentile": 9.06, "90th_percentile": 9.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 9.06, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.06, "10th_percentile": 9.06, "90th_percentile": 9.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 6.53, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.53, "10th_percentile": 6.53, "90th_percentile": 6.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 6.53, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.53, "10th_percentile": 6.53, "90th_percentile": 6.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 8.3, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.3, "10th_percentile": 8.3, "90th_percentile": 8.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 8.3, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.3, "10th_percentile": 8.3, "90th_percentile": 8.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 11.32, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.32, "10th_percentile": 11.32, "90th_percentile": 11.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ATORVASTATIN 10 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-19176", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00904-6290-61", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR BLUE CROSS MEDICARE ADVT", "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": "NWR 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." } ] } ] }, { "description": "ATORVASTATIN 10 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-19176", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "60505-2578-09", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR 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": "HEALTHLINK [125]", "plan_name": "NWR 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR BLUE CROSS MEDICARE ADVT", "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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" } ] } ] }, { "description": "ATORVASTATIN 20 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-19178", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "63304-0828-90", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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": "NWR 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": "GLOBAL EXCEL [1712]", "plan_name": "NWR 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": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR BLUE CROSS MEDICARE ADVT", "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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR 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" } ] } ] }, { "description": "ATORVASTATIN 40 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-19177", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "68084-0099-11", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.39, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR 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": "NWR BLUE CROSS MEDICARE ADVT", "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 HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "NWR AETNA", "standard_charge_dollar": 0.97, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 0.62, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 0.69, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 0.95, "10th_percentile": 0.95, "90th_percentile": 0.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1.46, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1.46, "10th_percentile": 1.46, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1.26, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1.26 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 0.39, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of 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": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.05, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.05, "10th_percentile": 1.05, "90th_percentile": 1.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 0.71, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.71, "10th_percentile": 0.71, "90th_percentile": 0.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "ATRICURE ABLATION PROBE LONG JAW OLL2", "code_information": [ { "code": "SUP-134985", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 2236.82, "maximum": 11589.75, "setting": "outpatient", "gross_charge": 11589.75, "discounted_cash": 8112.82, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11589.75, "10th_percentile": 11589.75, "90th_percentile": 11589.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11589.75, "10th_percentile": 11589.75, "90th_percentile": 11589.75, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11589.75, "10th_percentile": 11589.75, "90th_percentile": 11589.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 4514.21, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4514.21, "10th_percentile": 4514.21, "90th_percentile": 4514.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 4514.21, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4514.21, "10th_percentile": 4514.21, "90th_percentile": 4514.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 4135.22, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4135.22, "10th_percentile": 4135.22, "90th_percentile": 4135.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 4135.22, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4135.22, "10th_percentile": 4135.22, "90th_percentile": 4135.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3255.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3255.56, "10th_percentile": 3255.56, "90th_percentile": 3255.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3255.56, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3255.56, "10th_percentile": 3255.56, "90th_percentile": 3255.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 5644.21, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5644.21, "10th_percentile": 5644.21, "90th_percentile": 5644.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 2236.82, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 2236.82, "10th_percentile": 2236.82, "90th_percentile": 2236.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 6084.62, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6084.62, "10th_percentile": 6084.62, "90th_percentile": 6084.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 4114.36, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 4114.36, "10th_percentile": 4114.36, "90th_percentile": 4114.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 3986.87, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 3986.87, "10th_percentile": 3986.87, "90th_percentile": 3986.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 6165.75, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 6165.75, "10th_percentile": 6165.75, "90th_percentile": 6165.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 5493.54, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 5493.54, "10th_percentile": 5493.54, "90th_percentile": 5493.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 3517.49, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 3517.49, "10th_percentile": 3517.49, "90th_percentile": 3517.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 7444.1, "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": 7444.1, "10th_percentile": 7444.1, "90th_percentile": 7444.1, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 2283.18, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2283.18, "10th_percentile": 2283.18, "90th_percentile": 2283.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 9271.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 9271.8, "10th_percentile": 9271.8, "90th_percentile": 9271.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 6107.8, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6107.8, "10th_percentile": 6107.8, "90th_percentile": 6107.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 11589.75, "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 $11,589.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 11589.75, "10th_percentile": 11589.75, "90th_percentile": 11589.75, "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 $11,589.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 7301.54, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $7,301.54 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 7301.54, "10th_percentile": 7301.54, "90th_percentile": 7301.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $7,301.54 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3417.82, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3417.82, "10th_percentile": 3417.82, "90th_percentile": 3417.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 8692.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 8692.31, "10th_percentile": 8692.31, "90th_percentile": 8692.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 8112.83, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 8112.83, "10th_percentile": 8112.83, "90th_percentile": 8112.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 8460.52, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 8460.52, "10th_percentile": 8460.52, "90th_percentile": 8460.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 3581.23, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3581.23, "10th_percentile": 3581.23, "90th_percentile": 3581.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 11589.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 11589.75, "10th_percentile": 11589.75, "90th_percentile": 11589.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 5794.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 5794.88, "10th_percentile": 5794.88, "90th_percentile": 5794.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" } ] } ] }, { "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": 11.15, "maximum": 57.75, "setting": "outpatient", "gross_charge": 57.75, "discounted_cash": 40.42, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 57.75, "10th_percentile": 57.75, "90th_percentile": 57.75, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 57.75, "10th_percentile": 57.75, "90th_percentile": 57.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $57.75 @ 12.5% = $7.22 due to $0.00 Claim Price", "median_amount": 7.22, "10th_percentile": 7.22, "90th_percentile": 7.22, "count": "0", "methodology": "other", "additional_payer_notes": "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: $57.75 @ 12.5% = $7.22 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 27.6, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.6, "10th_percentile": 27.6, "90th_percentile": 27.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 27.6, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.6, "10th_percentile": 27.6, "90th_percentile": 27.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 27.6, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.6, "10th_percentile": 27.6, "90th_percentile": 27.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 20.61, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.61, "10th_percentile": 20.61, "90th_percentile": 20.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 20.61, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.61, "10th_percentile": 20.61, "90th_percentile": 20.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 19.58, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.58, "10th_percentile": 19.58, "90th_percentile": 19.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 19.58, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.58, "10th_percentile": 19.58, "90th_percentile": 19.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 30.72, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 30.72, "10th_percentile": 30.72, "90th_percentile": 30.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 30.32, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.32, "10th_percentile": 30.32, "90th_percentile": 30.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 11.15, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 11.15, "10th_percentile": 11.15, "90th_percentile": 11.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 19.87, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 19.87, "10th_percentile": 19.87, "90th_percentile": 19.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 20.5, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 20.5, "10th_percentile": 20.5, "90th_percentile": 20.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 43.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 43.31, "10th_percentile": 43.31, "90th_percentile": 43.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 28.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 28.88, "10th_percentile": 28.88, "90th_percentile": 28.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 57.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 57.75, "10th_percentile": 57.75, "90th_percentile": 57.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 17.53, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 17.53, "10th_percentile": 17.53, "90th_percentile": 17.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 42.16, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 42.16, "10th_percentile": 42.16, "90th_percentile": 42.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 40.43, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 40.43, "10th_percentile": 40.43, "90th_percentile": 40.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 46.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 46.2, "10th_percentile": 46.2, "90th_percentile": 46.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 57.75, "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 $57.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 57.75, "10th_percentile": 57.75, "90th_percentile": 57.75, "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 $57.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 36.38, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $36.38 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 36.38, "10th_percentile": 36.38, "90th_percentile": 36.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $36.38 so that total pmt for all claim lines does not exceed 63% of claim billed amount." } ] } ] }, { "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": "76329-3340-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 12.64, "maximum": 65.5, "setting": "outpatient", "gross_charge": 65.5, "discounted_cash": 45.85, "payers_information": [ { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 32.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 32.75, "10th_percentile": 32.75, "90th_percentile": 32.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.5, "10th_percentile": 65.5, "90th_percentile": 65.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 19.88, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 19.88, "10th_percentile": 19.88, "90th_percentile": 19.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 41.27, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $41.27 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 41.27, "10th_percentile": 41.27, "90th_percentile": 41.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $41.27 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 65.5, "10th_percentile": 65.5, "90th_percentile": 65.5, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 65.5, "10th_percentile": 65.5, "90th_percentile": 65.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $65.50 @ 12.5% = $8.19 due to $0.00 Claim Price", "median_amount": 8.19, "10th_percentile": 8.19, "90th_percentile": 8.19, "count": "0", "methodology": "other", "additional_payer_notes": "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: $65.50 @ 12.5% = $8.19 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 65.5, "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 $65.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 65.5, "10th_percentile": 65.5, "90th_percentile": 65.5, "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 $65.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 12.64, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 12.64, "10th_percentile": 12.64, "90th_percentile": 12.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 22.53, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 22.53, "10th_percentile": 22.53, "90th_percentile": 22.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 34.85, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 34.85, "10th_percentile": 34.85, "90th_percentile": 34.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 52.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 52.4, "10th_percentile": 52.4, "90th_percentile": 52.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 23.25, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 23.25, "10th_percentile": 23.25, "90th_percentile": 23.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 49.13, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 49.13, "10th_percentile": 49.13, "90th_percentile": 49.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 47.82, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 47.82, "10th_percentile": 47.82, "90th_percentile": 47.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 45.85, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 45.85, "10th_percentile": 45.85, "90th_percentile": 45.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 34.39, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.39, "10th_percentile": 34.39, "90th_percentile": 34.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 22.2, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.2, "10th_percentile": 22.2, "90th_percentile": 22.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 22.2, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.2, "10th_percentile": 22.2, "90th_percentile": 22.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 23.37, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.37, "10th_percentile": 23.37, "90th_percentile": 23.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 23.37, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.37, "10th_percentile": 23.37, "90th_percentile": 23.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 31.31, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 31.31, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 31.31, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "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": 38.84, "maximum": 201.25, "setting": "outpatient", "gross_charge": 201.25, "discounted_cash": 140.87, "payers_information": [ { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 201.25, "10th_percentile": 201.25, "90th_percentile": 201.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 201.25, "10th_percentile": 201.25, "90th_percentile": 201.25, "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": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 56.53, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 56.53, "10th_percentile": 56.53, "90th_percentile": 56.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 56.53, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 56.53, "10th_percentile": 56.53, "90th_percentile": 56.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 78.39, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 78.39, "10th_percentile": 78.39, "90th_percentile": 78.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 78.39, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 78.39, "10th_percentile": 78.39, "90th_percentile": 78.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 71.81, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.81, "10th_percentile": 71.81, "90th_percentile": 71.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 71.81, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.81, "10th_percentile": 71.81, "90th_percentile": 71.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 38.84, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 38.84, "10th_percentile": 38.84, "90th_percentile": 38.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 71.44, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 71.44, "10th_percentile": 71.44, "90th_percentile": 71.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 105.66, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 105.66, "10th_percentile": 105.66, "90th_percentile": 105.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 98.01, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 98.01, "10th_percentile": 98.01, "90th_percentile": 98.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 69.23, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 69.23, "10th_percentile": 69.23, "90th_percentile": 69.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 150.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 150.94, "10th_percentile": 150.94, "90th_percentile": 150.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 106.06, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 106.06, "10th_percentile": 106.06, "90th_percentile": 106.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 62.19, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.19, "10th_percentile": 62.19, "90th_percentile": 62.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 59.35, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 59.35, "10th_percentile": 59.35, "90th_percentile": 59.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 146.91, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 146.91, "10th_percentile": 146.91, "90th_percentile": 146.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 95.39, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 95.39, "10th_percentile": 95.39, "90th_percentile": 95.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 107.07, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 107.07, "10th_percentile": 107.07, "90th_percentile": 107.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 129.26, "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": 129.26, "10th_percentile": 129.26, "90th_percentile": 129.26, "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": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 161.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 161.0, "10th_percentile": 161.0, "90th_percentile": 161.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 61.08, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 61.08, "10th_percentile": 61.08, "90th_percentile": 61.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 140.88, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 140.88, "10th_percentile": 140.88, "90th_percentile": 140.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 100.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 100.63, "10th_percentile": 100.63, "90th_percentile": 100.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 201.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 201.25, "10th_percentile": 201.25, "90th_percentile": 201.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 39.65, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.65, "10th_percentile": 39.65, "90th_percentile": 39.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 126.79, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $126.79 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 126.79, "10th_percentile": 126.79, "90th_percentile": 126.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $126.79 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 201.25, "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 $201.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 201.25, "10th_percentile": 201.25, "90th_percentile": 201.25, "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 $201.25 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 201.25, "10th_percentile": 201.25, "90th_percentile": 201.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; 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": 165.69, "maximum": 858.5, "setting": "outpatient", "gross_charge": 858.5, "discounted_cash": 600.95, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 452.43, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 265.28, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.33, "10th_percentile": 71.33, "90th_percentile": 71.33, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 169.12, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.04, "10th_percentile": 32.04, "90th_percentile": 32.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 540.86, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $540.86 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 540.86, "10th_percentile": 540.86, "90th_percentile": 540.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $540.86 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 858.5, "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 $858.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 858.5, "10th_percentile": 858.5, "90th_percentile": 858.5, "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 $858.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 260.55, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 260.55, "10th_percentile": 260.55, "90th_percentile": 260.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 551.41, "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": 551.41, "10th_percentile": 551.41, "90th_percentile": 551.41, "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": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 456.72, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 456.72, "10th_percentile": 456.72, "90th_percentile": 456.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 429.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 429.25, "10th_percentile": 429.25, "90th_percentile": 429.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 406.93, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 406.93, "10th_percentile": 406.93, "90th_percentile": 406.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 858.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 858.5, "10th_percentile": 858.5, "90th_percentile": 858.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 643.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 643.88, "10th_percentile": 643.88, "90th_percentile": 643.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 626.71, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 626.71, "10th_percentile": 626.71, "90th_percentile": 626.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 600.95, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 600.95, "10th_percentile": 600.95, "90th_percentile": 600.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 304.77, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 304.77, "10th_percentile": 304.77, "90th_percentile": 304.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 418.09, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 418.09, "10th_percentile": 418.09, "90th_percentile": 418.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 165.69, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 165.69, "10th_percentile": 165.69, "90th_percentile": 165.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 295.32, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 295.32, "10th_percentile": 295.32, "90th_percentile": 295.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 450.71, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 450.71, "10th_percentile": 450.71, "90th_percentile": 450.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 686.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 686.8, "10th_percentile": 686.8, "90th_percentile": 686.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 291.03, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 291.03, "10th_percentile": 291.03, "90th_percentile": 291.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 291.03, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 291.03, "10th_percentile": 291.03, "90th_percentile": 291.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 306.31, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 306.31, "10th_percentile": 306.31, "90th_percentile": 306.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 306.31, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 306.31, "10th_percentile": 306.31, "90th_percentile": 306.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 410.36, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 410.36, "10th_percentile": 410.36, "90th_percentile": 410.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 410.36, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 410.36, "10th_percentile": 410.36, "90th_percentile": 410.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 410.36, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 410.36, "10th_percentile": 410.36, "90th_percentile": 410.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 858.5, "10th_percentile": 858.5, "90th_percentile": 858.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 858.5, "10th_percentile": 858.5, "90th_percentile": 858.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $858.50 @ 12.5% = $107.31 due to $0.00 Claim Price", "median_amount": 107.31, "10th_percentile": 107.31, "90th_percentile": 107.31, "count": "0", "methodology": "other", "additional_payer_notes": "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: $858.50 @ 12.5% = $107.31 due to $0.00 Claim Price" } ] } ] }, { "description": "AUG TIB 360 75X15MM RL/LM", "code_information": [ { "code": "SUP-375606", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 692.59, "maximum": 3588.53, "setting": "outpatient", "gross_charge": 3588.53, "discounted_cash": 2511.97, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 692.59, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1001.28, "10th_percentile": 1001.28, "90th_percentile": 1001.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 1108.86, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.6, "10th_percentile": 1188.6, "90th_percentile": 1188.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1715.32, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1715.32, "10th_percentile": 1715.32, "90th_percentile": 1715.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1715.32, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1715.32, "10th_percentile": 1715.32, "90th_percentile": 1715.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1715.32, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1715.32, "10th_percentile": 1715.32, "90th_percentile": 1715.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 1047.85, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1047.85, "10th_percentile": 1047.85, "90th_percentile": 1047.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1047.85, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1047.85, "10th_percentile": 1047.85, "90th_percentile": 1047.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 1280.39, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1280.39, "10th_percentile": 1280.39, "90th_percentile": 1280.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1280.39, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1280.39, "10th_percentile": 1280.39, "90th_percentile": 1280.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1216.51, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1216.51, "10th_percentile": 1216.51, "90th_percentile": 1216.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1216.51, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1216.51, "10th_percentile": 1216.51, "90th_percentile": 1216.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1891.16, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2627.73, "10th_percentile": 2627.73, "90th_percentile": 2627.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1909.1, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1909.1, "10th_percentile": 1909.1, "90th_percentile": 1909.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3588.53, "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 $3,588.53 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3588.53, "10th_percentile": 3588.53, "90th_percentile": 3588.53, "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 $3,588.53 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 2260.77, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,260.77 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 2260.77, "10th_percentile": 2260.77, "90th_percentile": 2260.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,260.77 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1273.93, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1273.93, "10th_percentile": 1273.93, "90th_percentile": 1273.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 706.94, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 706.94, "10th_percentile": 706.94, "90th_percentile": 706.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 3588.53, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3588.53, "10th_percentile": 3588.53, "90th_percentile": 3588.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 1234.45, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1234.45, "10th_percentile": 1234.45, "90th_percentile": 1234.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 2619.63, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 2619.63, "10th_percentile": 2619.63, "90th_percentile": 2619.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2691.4, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 2691.4, "10th_percentile": 2691.4, "90th_percentile": 2691.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 2304.91, "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": 2304.91, "10th_percentile": 2304.91, "90th_percentile": 2304.91, "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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2511.97, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 2511.97, "10th_percentile": 2511.97, "90th_percentile": 2511.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 1089.12, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 1089.12, "10th_percentile": 1089.12, "90th_percentile": 1089.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 2870.82, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2870.82, "10th_percentile": 2870.82, "90th_percentile": 2870.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 1700.96, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1700.96, "10th_percentile": 1700.96, "90th_percentile": 1700.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1794.27, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1794.27, "10th_percentile": 1794.27, "90th_percentile": 1794.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3588.53, "10th_percentile": 3588.53, "90th_percentile": 3588.53, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3588.53, "10th_percentile": 3588.53, "90th_percentile": 3588.53, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $3,588.53 @ 12.5% = $448.57 due to $0.00 Claim Price", "median_amount": 448.57, "10th_percentile": 448.57, "90th_percentile": 448.57, "count": "0", "methodology": "other", "additional_payer_notes": "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: $3,588.53 @ 12.5% = $448.57 due to $0.00 Claim Price" } ] } ] }, { "description": "AUG TIB BMT 360 63X5MM", "code_information": [ { "code": "SUP-313974", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 692.59, "maximum": 3588.53, "setting": "outpatient", "gross_charge": 3588.53, "discounted_cash": 2511.97, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 692.59, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1001.28, "10th_percentile": 1001.28, "90th_percentile": 1001.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 1108.86, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.6, "10th_percentile": 1188.6, "90th_percentile": 1188.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1715.32, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1715.32, "10th_percentile": 1715.32, "90th_percentile": 1715.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1715.32, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1715.32, "10th_percentile": 1715.32, "90th_percentile": 1715.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1715.32, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1715.32, "10th_percentile": 1715.32, "90th_percentile": 1715.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 1047.85, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1047.85, "10th_percentile": 1047.85, "90th_percentile": 1047.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1047.85, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1047.85, "10th_percentile": 1047.85, "90th_percentile": 1047.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 1280.39, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1280.39, "10th_percentile": 1280.39, "90th_percentile": 1280.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1280.39, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1280.39, "10th_percentile": 1280.39, "90th_percentile": 1280.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1216.51, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1216.51, "10th_percentile": 1216.51, "90th_percentile": 1216.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1216.51, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1216.51, "10th_percentile": 1216.51, "90th_percentile": 1216.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1891.16, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2627.73, "10th_percentile": 2627.73, "90th_percentile": 2627.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1909.1, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1909.1, "10th_percentile": 1909.1, "90th_percentile": 1909.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3588.53, "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 $3,588.53 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3588.53, "10th_percentile": 3588.53, "90th_percentile": 3588.53, "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 $3,588.53 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 2260.77, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,260.77 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 2260.77, "10th_percentile": 2260.77, "90th_percentile": 2260.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,260.77 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1273.93, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1273.93, "10th_percentile": 1273.93, "90th_percentile": 1273.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 706.94, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 706.94, "10th_percentile": 706.94, "90th_percentile": 706.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 3588.53, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3588.53, "10th_percentile": 3588.53, "90th_percentile": 3588.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 1234.45, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1234.45, "10th_percentile": 1234.45, "90th_percentile": 1234.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 2619.63, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 2619.63, "10th_percentile": 2619.63, "90th_percentile": 2619.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2691.4, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 2691.4, "10th_percentile": 2691.4, "90th_percentile": 2691.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 2304.91, "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": 2304.91, "10th_percentile": 2304.91, "90th_percentile": 2304.91, "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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2511.97, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 2511.97, "10th_percentile": 2511.97, "90th_percentile": 2511.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 1089.12, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 1089.12, "10th_percentile": 1089.12, "90th_percentile": 1089.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 2870.82, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2870.82, "10th_percentile": 2870.82, "90th_percentile": 2870.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 1700.96, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1700.96, "10th_percentile": 1700.96, "90th_percentile": 1700.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1794.27, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1794.27, "10th_percentile": 1794.27, "90th_percentile": 1794.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3588.53, "10th_percentile": 3588.53, "90th_percentile": 3588.53, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3588.53, "10th_percentile": 3588.53, "90th_percentile": 3588.53, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $3,588.53 @ 12.5% = $448.57 due to $0.00 Claim Price", "median_amount": 448.57, "10th_percentile": 448.57, "90th_percentile": 448.57, "count": "0", "methodology": "other", "additional_payer_notes": "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: $3,588.53 @ 12.5% = $448.57 due to $0.00 Claim Price" } ] } ] }, { "description": "AUGMENT BLOCK 5MM SZ 4 POSTERIOR 02-010-06-0541", "code_information": [ { "code": "SUP-344729", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 821.08, "maximum": 4254.3, "setting": "outpatient", "gross_charge": 4254.3, "discounted_cash": 2978.01, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 821.08, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1001.28, "10th_percentile": 1001.28, "90th_percentile": 1001.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 1314.58, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.6, "10th_percentile": 1188.6, "90th_percentile": 1188.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2033.56, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2033.56, "10th_percentile": 2033.56, "90th_percentile": 2033.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2033.56, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2033.56, "10th_percentile": 2033.56, "90th_percentile": 2033.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2033.56, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2033.56, "10th_percentile": 2033.56, "90th_percentile": 2033.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 1517.93, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1517.93, "10th_percentile": 1517.93, "90th_percentile": 1517.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1517.93, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1517.93, "10th_percentile": 1517.93, "90th_percentile": 1517.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1442.21, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1442.21, "10th_percentile": 1442.21, "90th_percentile": 1442.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1442.21, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1442.21, "10th_percentile": 1442.21, "90th_percentile": 1442.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 1242.26, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1242.26, "10th_percentile": 1242.26, "90th_percentile": 1242.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1242.26, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1242.26, "10th_percentile": 1242.26, "90th_percentile": 1242.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 2242.02, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2627.73, "10th_percentile": 2627.73, "90th_percentile": 2627.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4254.3, "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 $4,254.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4254.3, "10th_percentile": 4254.3, "90th_percentile": 4254.3, "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 $4,254.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 2680.21, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,680.21 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 2680.21, "10th_percentile": 2680.21, "90th_percentile": 2680.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,680.21 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 2732.54, "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": 2732.54, "10th_percentile": 2732.54, "90th_percentile": 2732.54, "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": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 2016.54, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 2016.54, "10th_percentile": 2016.54, "90th_percentile": 2016.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2978.01, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 2978.01, "10th_percentile": 2978.01, "90th_percentile": 2978.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 2263.29, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 2263.29, "10th_percentile": 2263.29, "90th_percentile": 2263.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 3403.44, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 3403.44, "10th_percentile": 3403.44, "90th_percentile": 3403.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 838.1, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 838.1, "10th_percentile": 838.1, "90th_percentile": 838.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1510.28, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1510.28, "10th_percentile": 1510.28, "90th_percentile": 1510.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 3190.73, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 3190.73, "10th_percentile": 3190.73, "90th_percentile": 3190.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 1463.48, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1463.48, "10th_percentile": 1463.48, "90th_percentile": 1463.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 4254.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4254.3, "10th_percentile": 4254.3, "90th_percentile": 4254.3, "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": "NWR HFN PPO", "standard_charge_dollar": 3105.64, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 3105.64, "10th_percentile": 3105.64, "90th_percentile": 3105.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 1291.18, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 1291.18, "10th_percentile": 1291.18, "90th_percentile": 1291.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 2127.15, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 2127.15, "10th_percentile": 2127.15, "90th_percentile": 2127.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4254.3, "10th_percentile": 4254.3, "90th_percentile": 4254.3, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4254.3, "10th_percentile": 4254.3, "90th_percentile": 4254.3, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $4,254.30 @ 12.5% = $531.79 due to $0.00 Claim Price", "median_amount": 531.79, "10th_percentile": 531.79, "90th_percentile": 531.79, "count": "0", "methodology": "other", "additional_payer_notes": "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: $4,254.30 @ 12.5% = $531.79 due to $0.00 Claim Price" } ] } ] }, { "description": "AUGMENT FEM 4MM SZ 4 DISTAL KNEE CEMENTED REV ATTUNE", "code_information": [ { "code": "SUP-354851", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 862.92, "maximum": 4471.1, "setting": "outpatient", "gross_charge": 4471.1, "discounted_cash": 3129.77, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 862.92, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1001.28, "10th_percentile": 1001.28, "90th_percentile": 1001.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 1381.57, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.6, "10th_percentile": 1188.6, "90th_percentile": 1188.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2137.19, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2137.19, "10th_percentile": 2137.19, "90th_percentile": 2137.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2137.19, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2137.19, "10th_percentile": 2137.19, "90th_percentile": 2137.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2137.19, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2137.19, "10th_percentile": 2137.19, "90th_percentile": 2137.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1515.7, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1515.7, "10th_percentile": 1515.7, "90th_percentile": 1515.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1515.7, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1515.7, "10th_percentile": 1515.7, "90th_percentile": 1515.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 1595.29, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1595.29, "10th_percentile": 1595.29, "90th_percentile": 1595.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1595.29, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1595.29, "10th_percentile": 1595.29, "90th_percentile": 1595.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1305.56, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1305.56, "10th_percentile": 1305.56, "90th_percentile": 1305.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 1305.56, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1305.56, "10th_percentile": 1305.56, "90th_percentile": 1305.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 2816.79, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,816.79 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 2816.79, "10th_percentile": 2816.79, "90th_percentile": 2816.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,816.79 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4471.1, "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 $4,471.10 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4471.1, "10th_percentile": 4471.1, "90th_percentile": 4471.1, "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 $4,471.10 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 4471.1, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4471.1, "10th_percentile": 4471.1, "90th_percentile": 4471.1, "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": "NWR HFN PPO", "standard_charge_dollar": 3263.9, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 3263.9, "10th_percentile": 3263.9, "90th_percentile": 3263.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 2119.3, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 2119.3, "10th_percentile": 2119.3, "90th_percentile": 2119.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 3129.77, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 3129.77, "10th_percentile": 3129.77, "90th_percentile": 3129.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 1356.98, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 1356.98, "10th_percentile": 1356.98, "90th_percentile": 1356.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 2235.55, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 2235.55, "10th_percentile": 2235.55, "90th_percentile": 2235.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 2378.63, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 2378.63, "10th_percentile": 2378.63, "90th_percentile": 2378.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 3353.33, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 3353.33, "10th_percentile": 3353.33, "90th_percentile": 3353.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 1538.06, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1538.06, "10th_percentile": 1538.06, "90th_percentile": 1538.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 880.81, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 880.81, "10th_percentile": 880.81, "90th_percentile": 880.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1587.24, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1587.24, "10th_percentile": 1587.24, "90th_percentile": 1587.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 2871.79, "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": 2871.79, "10th_percentile": 2871.79, "90th_percentile": 2871.79, "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": "NWR BEECHSTREET", "standard_charge_dollar": 3576.88, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 3576.88, "10th_percentile": 3576.88, "90th_percentile": 3576.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 2356.27, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2627.73, "10th_percentile": 2627.73, "90th_percentile": 2627.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4471.1, "10th_percentile": 4471.1, "90th_percentile": 4471.1, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4471.1, "10th_percentile": 4471.1, "90th_percentile": 4471.1, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $4,471.10 @ 12.5% = $558.89 due to $0.00 Claim Price", "median_amount": 558.89, "10th_percentile": 558.89, "90th_percentile": 558.89, "count": "0", "methodology": "other", "additional_payer_notes": "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: $4,471.10 @ 12.5% = $558.89 due to $0.00 Claim Price" } ] } ] }, { "description": "AUGMENT TIB 2 10MM HALF BLOCK L RT FIT RBK", "code_information": [ { "code": "SUP-354818", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 821.08, "maximum": 4254.3, "setting": "outpatient", "gross_charge": 4254.3, "discounted_cash": 2978.01, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 821.08, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1001.28, "10th_percentile": 1001.28, "90th_percentile": 1001.28, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 1314.58, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.6, "10th_percentile": 1188.6, "90th_percentile": 1188.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2033.56, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2033.56, "10th_percentile": 2033.56, "90th_percentile": 2033.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2033.56, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2033.56, "10th_percentile": 2033.56, "90th_percentile": 2033.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 2033.56, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2033.56, "10th_percentile": 2033.56, "90th_percentile": 2033.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 1242.26, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1242.26, "10th_percentile": 1242.26, "90th_percentile": 1242.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 1242.26, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1242.26, "10th_percentile": 1242.26, "90th_percentile": 1242.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 1517.93, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1517.93, "10th_percentile": 1517.93, "90th_percentile": 1517.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1517.93, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1517.93, "10th_percentile": 1517.93, "90th_percentile": 1517.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1442.21, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1442.21, "10th_percentile": 1442.21, "90th_percentile": 1442.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1442.21, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1442.21, "10th_percentile": 1442.21, "90th_percentile": 1442.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 2242.02, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2627.73, "10th_percentile": 2627.73, "90th_percentile": 2627.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 2263.29, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 2263.29, "10th_percentile": 2263.29, "90th_percentile": 2263.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4254.3, "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 $4,254.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4254.3, "10th_percentile": 4254.3, "90th_percentile": 4254.3, "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 $4,254.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 2680.21, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,680.21 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 2680.21, "10th_percentile": 2680.21, "90th_percentile": 2680.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2,680.21 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1510.28, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1510.28, "10th_percentile": 1510.28, "90th_percentile": 1510.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 838.1, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 838.1, "10th_percentile": 838.1, "90th_percentile": 838.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 4254.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4254.3, "10th_percentile": 4254.3, "90th_percentile": 4254.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 1463.48, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1463.48, "10th_percentile": 1463.48, "90th_percentile": 1463.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 3105.64, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 3105.64, "10th_percentile": 3105.64, "90th_percentile": 3105.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 3190.73, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 3190.73, "10th_percentile": 3190.73, "90th_percentile": 3190.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 2732.54, "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": 2732.54, "10th_percentile": 2732.54, "90th_percentile": 2732.54, "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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2978.01, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 2978.01, "10th_percentile": 2978.01, "90th_percentile": 2978.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 1291.18, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 1291.18, "10th_percentile": 1291.18, "90th_percentile": 1291.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 3403.44, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 3403.44, "10th_percentile": 3403.44, "90th_percentile": 3403.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 2016.54, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 2016.54, "10th_percentile": 2016.54, "90th_percentile": 2016.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 2127.15, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 2127.15, "10th_percentile": 2127.15, "90th_percentile": 2127.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4254.3, "10th_percentile": 4254.3, "90th_percentile": 4254.3, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4254.3, "10th_percentile": 4254.3, "90th_percentile": 4254.3, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $4,254.30 @ 12.5% = $531.79 due to $0.00 Claim Price", "median_amount": 531.79, "10th_percentile": 531.79, "90th_percentile": 531.79, "count": "0", "methodology": "other", "additional_payer_notes": "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: $4,254.30 @ 12.5% = $531.79 due to $0.00 Claim Price" } ] } ] }, { "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": 2323.7, "maximum": 12039.91, "setting": "outpatient", "gross_charge": 12039.91, "discounted_cash": 8427.94, "payers_information": [ { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 6019.96, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 6019.96, "10th_percentile": 6019.96, "90th_percentile": 6019.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 6345.03, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6345.03, "10th_percentile": 6345.03, "90th_percentile": 6345.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 7733.23, "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": 7733.23, "10th_percentile": 7733.23, "90th_percentile": 7733.23, "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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 8427.94, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 8427.94, "10th_percentile": 8427.94, "90th_percentile": 8427.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 3720.33, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3720.33, "10th_percentile": 3720.33, "90th_percentile": 3720.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC CORE", "standard_charge_dollar": 5706.92, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 5706.92, "10th_percentile": 5706.92, "90th_percentile": 5706.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 12039.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12039.91, "10th_percentile": 12039.91, "90th_percentile": 12039.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 3654.11, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 3654.11, "10th_percentile": 3654.11, "90th_percentile": 3654.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 9029.93, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 9029.93, "10th_percentile": 9029.93, "90th_percentile": 9029.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 8789.13, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 8789.13, "10th_percentile": 8789.13, "90th_percentile": 8789.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 7585.14, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $7,585.14 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 7585.14, "10th_percentile": 7585.14, "90th_percentile": 7585.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $7,585.14 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $12,039.91 @ 12.5% = $1,504.99 due to $0.00 Claim Price", "median_amount": 1504.99, "10th_percentile": 1504.99, "90th_percentile": 1504.99, "count": "0", "methodology": "other", "additional_payer_notes": "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: $12,039.91 @ 12.5% = $1,504.99 due to $0.00 Claim Price" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5755.08, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5755.08, "10th_percentile": 5755.08, "90th_percentile": 5755.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5755.08, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5755.08, "10th_percentile": 5755.08, "90th_percentile": 5755.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5755.08, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5755.08, "10th_percentile": 5755.08, "90th_percentile": 5755.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 4295.84, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4295.84, "10th_percentile": 4295.84, "90th_percentile": 4295.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 4295.84, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4295.84, "10th_percentile": 4295.84, "90th_percentile": 4295.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 4081.53, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4081.53, "10th_percentile": 4081.53, "90th_percentile": 4081.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 4081.53, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4081.53, "10th_percentile": 4081.53, "90th_percentile": 4081.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 3515.65, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3515.65, "10th_percentile": 3515.65, "90th_percentile": 3515.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 3515.65, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3515.65, "10th_percentile": 3515.65, "90th_percentile": 3515.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 2323.7, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 2242.95, "10th_percentile": 2242.95, "90th_percentile": 2242.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 12039.91, "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 $12,039.91 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 12039.91, "10th_percentile": 12039.91, "90th_percentile": 12039.91, "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 $12,039.91 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 2371.86, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2371.86, "10th_percentile": 2371.86, "90th_percentile": 2371.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 4274.17, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 4274.17, "10th_percentile": 4274.17, "90th_percentile": 4274.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 6405.23, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 6405.23, "10th_percentile": 6405.23, "90th_percentile": 6405.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 4141.73, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 4141.73, "10th_percentile": 4141.73, "90th_percentile": 4141.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 9631.93, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 9631.93, "10th_percentile": 9631.93, "90th_percentile": 9631.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12039.91, "10th_percentile": 12039.91, "90th_percentile": 12039.91, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12039.91, "10th_percentile": 12039.91, "90th_percentile": 12039.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "AXIAL CNCTR 5.5/6.35", "code_information": [ { "code": "SUP-112326", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 314.81, "maximum": 1631.15, "setting": "outpatient", "gross_charge": 1631.15, "discounted_cash": 1141.8, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $1,631.15 @ 12.5% = $203.89 due to $0.00 Claim Price", "median_amount": 203.89, "10th_percentile": 203.89, "90th_percentile": 203.89, "count": "0", "methodology": "other", "additional_payer_notes": "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: $1,631.15 @ 12.5% = $203.89 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 859.62, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.47, "10th_percentile": 45.47, "90th_percentile": 45.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR PHCS PPO", "standard_charge_dollar": 1027.62, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,027.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1027.62, "10th_percentile": 1027.62, "90th_percentile": 1027.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,027.62 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1631.15, "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 $1,631.15 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "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 $1,631.15 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 561.12, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 561.12, "10th_percentile": 561.12, "90th_percentile": 561.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 579.06, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 579.06, "10th_percentile": 579.06, "90th_percentile": 579.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1304.92, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1304.92, "10th_percentile": 1304.92, "90th_percentile": 1304.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 773.17, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 773.17, "10th_percentile": 773.17, "90th_percentile": 773.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1141.81, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1141.81, "10th_percentile": 1141.81, "90th_percentile": 1141.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 1047.69, "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": 1047.69, "10th_percentile": 1047.69, "90th_percentile": 1047.69, "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": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1190.74, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1190.74, "10th_percentile": 1190.74, "90th_percentile": 1190.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1223.36, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1223.36, "10th_percentile": 1223.36, "90th_percentile": 1223.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 504.03, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 504.03, "10th_percentile": 504.03, "90th_percentile": 504.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 495.05, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 495.05, "10th_percentile": 495.05, "90th_percentile": 495.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 815.58, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 815.58, "10th_percentile": 815.58, "90th_percentile": 815.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 321.34, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 321.34, "10th_percentile": 321.34, "90th_percentile": 321.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 867.77, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 867.77, "10th_percentile": 867.77, "90th_percentile": 867.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 314.81, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 8.1, "10th_percentile": 8.1, "90th_percentile": 8.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 1631.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1631.15, "10th_percentile": 1631.15, "90th_percentile": 1631.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 476.3, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 476.3, "10th_percentile": 476.3, "90th_percentile": 476.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 476.3, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 476.3, "10th_percentile": 476.3, "90th_percentile": 476.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 552.96, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 552.96, "10th_percentile": 552.96, "90th_percentile": 552.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 552.96, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 552.96, "10th_percentile": 552.96, "90th_percentile": 552.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 581.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 581.99, "10th_percentile": 581.99, "90th_percentile": 581.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 581.99, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 581.99, "10th_percentile": 581.99, "90th_percentile": 581.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 779.69, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 779.69, "10th_percentile": 779.69, "90th_percentile": 779.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "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": 470.56, "maximum": 2438.14, "setting": "outpatient", "gross_charge": 2438.14, "discounted_cash": 1706.7, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2438.14, "10th_percentile": 2438.14, "90th_percentile": 2438.14, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2438.14, "10th_percentile": 2438.14, "90th_percentile": 2438.14, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2438.14, "10th_percentile": 2438.14, "90th_percentile": 2438.14, "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": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 684.87, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 684.87, "10th_percentile": 684.87, "90th_percentile": 684.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 684.87, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 684.87, "10th_percentile": 684.87, "90th_percentile": 684.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 869.93, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 869.93, "10th_percentile": 869.93, "90th_percentile": 869.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 869.93, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 869.93, "10th_percentile": 869.93, "90th_percentile": 869.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 949.66, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 949.66, "10th_percentile": 949.66, "90th_percentile": 949.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 949.66, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 949.66, "10th_percentile": 949.66, "90th_percentile": 949.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 865.54, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 865.54, "10th_percentile": 865.54, "90th_percentile": 865.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1280.02, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1280.02, "10th_percentile": 1280.02, "90th_percentile": 1280.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 838.72, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 838.72, "10th_percentile": 838.72, "90th_percentile": 838.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 1187.37, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1187.37, "10th_percentile": 1187.37, "90th_percentile": 1187.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 470.56, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 470.56, "10th_percentile": 470.56, "90th_percentile": 470.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 1566.02, "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": 1566.02, "10th_percentile": 1566.02, "90th_percentile": 1566.02, "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": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 1828.61, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 1828.61, "10th_percentile": 1828.61, "90th_percentile": 1828.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 719.01, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 719.01, "10th_percentile": 719.01, "90th_percentile": 719.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 739.98, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 739.98, "10th_percentile": 739.98, "90th_percentile": 739.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 1155.68, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1155.68, "10th_percentile": 1155.68, "90th_percentile": 1155.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 1779.84, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 1779.84, "10th_percentile": 1779.84, "90th_percentile": 1779.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1297.09, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1297.09, "10th_percentile": 1297.09, "90th_percentile": 1297.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 1536.03, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,536.03 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 1536.03, "10th_percentile": 1536.03, "90th_percentile": 1536.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $1,536.03 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2438.14, "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 $2,438.14 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2438.14, "10th_percentile": 2438.14, "90th_percentile": 2438.14, "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 $2,438.14 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 2438.14, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2438.14, "10th_percentile": 2438.14, "90th_percentile": 2438.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 480.31, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 480.31, "10th_percentile": 480.31, "90th_percentile": 480.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 1284.9, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1284.9, "10th_percentile": 1284.9, "90th_percentile": 1284.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1219.07, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1219.07, "10th_percentile": 1219.07, "90th_percentile": 1219.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 1950.51, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1950.51, "10th_percentile": 1950.51, "90th_percentile": 1950.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 753.39, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 753.39, "10th_percentile": 753.39, "90th_percentile": 753.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 1706.7, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 1706.7, "10th_percentile": 1706.7, "90th_percentile": 1706.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" } ] } ] }, { "description": "AXIUM PRIME 3MMX6CM EXTRA SOFT COIL EMBOL BARE 3D", "code_information": [ { "code": "SUP-358532", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1412.51, "maximum": 7318.71, "setting": "outpatient", "gross_charge": 7318.71, "discounted_cash": 5123.1, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $7,318.71 @ 12.5% = $914.84 due to $0.00 Claim Price", "median_amount": 914.84, "10th_percentile": 914.84, "90th_percentile": 914.84, "count": "0", "methodology": "other", "additional_payer_notes": "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: $7,318.71 @ 12.5% = $914.84 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7318.71, "10th_percentile": 7318.71, "90th_percentile": 7318.71, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7318.71, "10th_percentile": 7318.71, "90th_percentile": 7318.71, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 2517.64, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 2517.64, "10th_percentile": 2517.64, "90th_percentile": 2517.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 3659.36, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 3659.36, "10th_percentile": 3659.36, "90th_percentile": 3659.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 1441.79, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1441.79, "10th_percentile": 1441.79, "90th_percentile": 1441.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 5342.66, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 5342.66, "10th_percentile": 5342.66, "90th_percentile": 5342.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 2221.23, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 2221.23, "10th_percentile": 2221.23, "90th_percentile": 2221.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 3469.07, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 3469.07, "10th_percentile": 3469.07, "90th_percentile": 3469.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 5489.03, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 5489.03, "10th_percentile": 5489.03, "90th_percentile": 5489.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 2598.14, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 2598.14, "10th_percentile": 2598.14, "90th_percentile": 2598.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 4700.81, "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": 4700.81, "10th_percentile": 4700.81, "90th_percentile": 4700.81, "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": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 5854.97, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 5854.97, "10th_percentile": 5854.97, "90th_percentile": 5854.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 3893.55, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 3893.55, "10th_percentile": 3893.55, "90th_percentile": 3893.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 2261.48, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2261.48, "10th_percentile": 2261.48, "90th_percentile": 2261.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 5123.1, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 5123.1, "10th_percentile": 5123.1, "90th_percentile": 5123.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 7318.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7318.71, "10th_percentile": 7318.71, "90th_percentile": 7318.71, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 7318.71, "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 $7,318.71 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 7318.71, "10th_percentile": 7318.71, "90th_percentile": 7318.71, "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 $7,318.71 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 4610.79, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $4,610.79 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 4610.79, "10th_percentile": 4610.79, "90th_percentile": 4610.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $4,610.79 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 3856.96, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.47, "10th_percentile": 45.47, "90th_percentile": 45.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 1412.51, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 8.1, "10th_percentile": 8.1, "90th_percentile": 8.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 2481.04, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2481.04, "10th_percentile": 2481.04, "90th_percentile": 2481.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 2481.04, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2481.04, "10th_percentile": 2481.04, "90th_percentile": 2481.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 2611.32, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2611.32, "10th_percentile": 2611.32, "90th_percentile": 2611.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 2611.32, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2611.32, "10th_percentile": 2611.32, "90th_percentile": 2611.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 2137.06, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2137.06, "10th_percentile": 2137.06, "90th_percentile": 2137.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 2137.06, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2137.06, "10th_percentile": 2137.06, "90th_percentile": 2137.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3498.34, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3498.34, "10th_percentile": 3498.34, "90th_percentile": 3498.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3498.34, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3498.34, "10th_percentile": 3498.34, "90th_percentile": 3498.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3498.34, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3498.34, "10th_percentile": 3498.34, "90th_percentile": 3498.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "AXIUM PRIME COIL DETACHABLE 3D FRAME 4MMX8CM", "code_information": [ { "code": "SUP-357942", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1574.06, "maximum": 8155.75, "setting": "outpatient", "gross_charge": 8155.75, "discounted_cash": 5709.02, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $8,155.75 @ 12.5% = $1,019.47 due to $0.00 Claim Price", "median_amount": 1019.47, "10th_percentile": 1019.47, "90th_percentile": 1019.47, "count": "0", "methodology": "other", "additional_payer_notes": "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: $8,155.75 @ 12.5% = $1,019.47 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8155.75, "10th_percentile": 8155.75, "90th_percentile": 8155.75, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8155.75, "10th_percentile": 8155.75, "90th_percentile": 8155.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 1574.06, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 8.1, "10th_percentile": 8.1, "90th_percentile": 8.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 4298.08, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.47, "10th_percentile": 45.47, "90th_percentile": 45.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 8155.75, "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 $8,155.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8155.75, "10th_percentile": 8155.75, "90th_percentile": 8155.75, "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 $8,155.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 5138.12, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $5,138.12 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 5138.12, "10th_percentile": 5138.12, "90th_percentile": 5138.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $5,138.12 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 8155.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8155.75, "10th_percentile": 8155.75, "90th_percentile": 8155.75, "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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 5709.03, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 5709.03, "10th_percentile": 5709.03, "90th_percentile": 5709.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 6524.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 6524.6, "10th_percentile": 6524.6, "90th_percentile": 6524.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 3865.83, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 3865.83, "10th_percentile": 3865.83, "90th_percentile": 3865.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 5238.44, "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": 5238.44, "10th_percentile": 5238.44, "90th_percentile": 5238.44, "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": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 2805.58, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 2805.58, "10th_percentile": 2805.58, "90th_percentile": 2805.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 6116.81, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 6116.81, "10th_percentile": 6116.81, "90th_percentile": 6116.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 4338.86, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 4338.86, "10th_percentile": 4338.86, "90th_percentile": 4338.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 4077.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 4077.88, "10th_percentile": 4077.88, "90th_percentile": 4077.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 5953.7, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 5953.7, "10th_percentile": 5953.7, "90th_percentile": 5953.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 1606.68, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1606.68, "10th_percentile": 1606.68, "90th_percentile": 1606.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 2895.29, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 2895.29, "10th_percentile": 2895.29, "90th_percentile": 2895.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 2475.27, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 2475.27, "10th_percentile": 2475.27, "90th_percentile": 2475.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 2520.13, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2520.13, "10th_percentile": 2520.13, "90th_percentile": 2520.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 2909.97, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2909.97, "10th_percentile": 2909.97, "90th_percentile": 2909.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 2909.97, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2909.97, "10th_percentile": 2909.97, "90th_percentile": 2909.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 2764.8, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2764.8, "10th_percentile": 2764.8, "90th_percentile": 2764.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 2764.8, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2764.8, "10th_percentile": 2764.8, "90th_percentile": 2764.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 2381.48, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2381.48, "10th_percentile": 2381.48, "90th_percentile": 2381.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 2381.48, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2381.48, "10th_percentile": 2381.48, "90th_percentile": 2381.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3898.45, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3898.45, "10th_percentile": 3898.45, "90th_percentile": 3898.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3898.45, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3898.45, "10th_percentile": 3898.45, "90th_percentile": 3898.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3898.45, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3898.45, "10th_percentile": 3898.45, "90th_percentile": 3898.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "AZITHROMYCIN 100 MG/5 ML ORAL SUSR", "drug_information": { "unit": 5.0, "type": "ML" }, "code_information": [ { "code": "RX-15796", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00093-2027-23", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.27, "maximum": 11.75, "setting": "outpatient", "gross_charge": 11.75, "discounted_cash": 8.22, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 7.4, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $7.40 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 7.4, "10th_percentile": 7.4, "90th_percentile": 7.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $7.40 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 11.75, "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 $11.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 11.75, "10th_percentile": 11.75, "90th_percentile": 11.75, "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 $11.75 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 8.23, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 8.23, "10th_percentile": 8.23, "90th_percentile": 8.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 3.57, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 3.57, "10th_percentile": 3.57, "90th_percentile": 3.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 5.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% 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 Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 8.58, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% 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 Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 8.81, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 8.81, "10th_percentile": 8.81, "90th_percentile": 8.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 2.31, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.31, "10th_percentile": 2.31, "90th_percentile": 2.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 11.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 11.75, "10th_percentile": 11.75, "90th_percentile": 11.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 7.55, "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": 7.55, "10th_percentile": 7.55, "90th_percentile": 7.55, "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": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 6.25, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 6.25, "10th_percentile": 6.25, "90th_percentile": 6.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3.47, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.47, "10th_percentile": 3.47, "90th_percentile": 3.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 9.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 9.4, "10th_percentile": 9.4, "90th_percentile": 9.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 5.57, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 5.57, "10th_percentile": 5.57, "90th_percentile": 5.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 6.19, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.19, "10th_percentile": 6.19, "90th_percentile": 6.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 3.63, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 4.04, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% 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; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 5.72, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.72, "10th_percentile": 5.72, "90th_percentile": 5.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 2.27, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 2.27, "10th_percentile": 2.27, "90th_percentile": 2.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 4.17, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 4.17, "10th_percentile": 4.17, "90th_percentile": 4.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 6.17, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.17, "10th_percentile": 6.17, "90th_percentile": 6.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 3.3, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.3, "10th_percentile": 3.3, "90th_percentile": 3.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3.3, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.3, "10th_percentile": 3.3, "90th_percentile": 3.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 4.58, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.58, "10th_percentile": 4.58, "90th_percentile": 4.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 4.58, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.58, "10th_percentile": 4.58, "90th_percentile": 4.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 4.19, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 4.19, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.75, "10th_percentile": 11.75, "90th_percentile": 11.75, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.75, "10th_percentile": 11.75, "90th_percentile": 11.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.75, "10th_percentile": 11.75, "90th_percentile": 11.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "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": "50268-0074-11", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.63, "maximum": 3.25, "setting": "outpatient", "gross_charge": 3.25, "discounted_cash": 2.27, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "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": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "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": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $3.25 @ 12.5% = $0.41 due to $0.00 Claim Price", "median_amount": 0.41, "10th_percentile": 0.41, "90th_percentile": 0.41, "count": "0", "methodology": "other", "additional_payer_notes": "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: $3.25 @ 12.5% = $0.41 due to $0.00 Claim Price" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR 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": "NWR AETNA", "standard_charge_dollar": 1.58, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.58, "10th_percentile": 1.58, "90th_percentile": 1.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 1.12, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1.12, "10th_percentile": 1.12, "90th_percentile": 1.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1.71, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1.15, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1.15, "10th_percentile": 1.15, "90th_percentile": 1.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.63, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.63, "10th_percentile": 0.63, "90th_percentile": 0.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.16, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.16, "10th_percentile": 1.16, "90th_percentile": 1.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1.1, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR 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": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.55, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.55, "10th_percentile": 1.55, "90th_percentile": 1.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.55, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.55, "10th_percentile": 1.55, "90th_percentile": 1.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.55, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.55, "10th_percentile": 1.55, "90th_percentile": 1.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.16, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.16, "10th_percentile": 1.16, "90th_percentile": 1.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR 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": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1.1, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 1.73, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 1.73, "10th_percentile": 1.73, "90th_percentile": 1.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 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": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2.28, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 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": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 2.37, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% 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; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR 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": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 0.99, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 0.99, "10th_percentile": 0.99, "90th_percentile": 0.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 2.05, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2.05 so that total pmt for all claim lines does not exceed 63% 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 OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2.05 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR 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": "NWR UHC CORE", "standard_charge_dollar": 1.54, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1.54, "10th_percentile": 1.54, "90th_percentile": 1.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.71, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "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": "60687-0742-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.72, "maximum": 3.75, "setting": "outpatient", "gross_charge": 3.75, "discounted_cash": 2.62, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 1.83, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.83, "10th_percentile": 1.83, "90th_percentile": 1.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 1.29, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1.29, "10th_percentile": 1.29, "90th_percentile": 1.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 1.97, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.97, "10th_percentile": 1.97, "90th_percentile": 1.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1.33, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1.33, "10th_percentile": 1.33, "90th_percentile": 1.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.72, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 0.72, "10th_percentile": 0.72, "90th_percentile": 0.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.34, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1.27, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 3.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 3.0, "10th_percentile": 3.0, "90th_percentile": 3.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.79, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.79, "10th_percentile": 1.79, "90th_percentile": 1.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.79, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.79, "10th_percentile": 1.79, "90th_percentile": 1.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.79, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.79, "10th_percentile": 1.79, "90th_percentile": 1.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.34, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3.75, "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 $3.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "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. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3.75 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": "NWR BCBS PPO", "standard_charge_dollar": 1.27, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 2.0, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% 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; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 2.81, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 2.81, "10th_percentile": 2.81, "90th_percentile": 2.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 2.63, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 2.63, "10th_percentile": 2.63, "90th_percentile": 2.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 2.74, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% 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 Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 1.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.88, "10th_percentile": 1.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 1.14, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 2.36, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2.36 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 2.36, "10th_percentile": 2.36, "90th_percentile": 2.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $2.36 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 2.41, "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": 2.41, "10th_percentile": 2.41, "90th_percentile": 2.41, "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": "NWR UHC CORE", "standard_charge_dollar": 1.78, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 1.78, "10th_percentile": 1.78, "90th_percentile": 1.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 1.98, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.98, "10th_percentile": 1.98, "90th_percentile": 1.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% 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 OP Services; 100% Billed" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3.75, "10th_percentile": 3.75, "90th_percentile": 3.75, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3.75, "10th_percentile": 3.75, "90th_percentile": 3.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $3.75 @ 12.5% = $0.47 due to $0.00 Claim Price", "median_amount": 0.47, "10th_percentile": 0.47, "90th_percentile": 0.47, "count": "0", "methodology": "other", "additional_payer_notes": "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: $3.75 @ 12.5% = $0.47 due to $0.00 Claim Price" } ] } ] }, { "description": "AZITHROMYCIN 500 MG IV SOLR", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-21063", "type": "CDM" }, { "code": "J0456", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "63323-0398-41", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.12, "maximum": 11.0, "setting": "outpatient", "gross_charge": 11.0, "discounted_cash": 7.7, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $11.00 @ 12.5% = $1.38 due to $0.00 Claim Price", "median_amount": 1.38, "10th_percentile": 1.38, "90th_percentile": 1.38, "count": "0", "methodology": "other", "additional_payer_notes": "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: $11.00 @ 12.5% = $1.38 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 6.93, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $6.93 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 6.93, "10th_percentile": 6.93, "90th_percentile": 6.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $6.93 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 11.0, "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 $11.00 so that total pmt for all claim lines does not exceed 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. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $11.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 5.85, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 5.85, "10th_percentile": 5.85, "90th_percentile": 5.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 11.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 3.34, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 3.34, "10th_percentile": 3.34, "90th_percentile": 3.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 8.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 8.25, "10th_percentile": 8.25, "90th_percentile": 8.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 8.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 8.8, "10th_percentile": 8.8, "90th_percentile": 8.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 5.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 5.5, "10th_percentile": 5.5, "90th_percentile": 5.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 5.78, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.78, "10th_percentile": 5.78, "90th_percentile": 5.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 2.12, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% 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 Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 3.78, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 3.78, "10th_percentile": 3.78, "90th_percentile": 3.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 7.7, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 7.7, "10th_percentile": 7.7, "90th_percentile": 7.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 3.91, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 3.91, "10th_percentile": 3.91, "90th_percentile": 3.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 8.03, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 8.03, "10th_percentile": 8.03, "90th_percentile": 8.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 3.73, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.73, "10th_percentile": 3.73, "90th_percentile": 3.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 3.73, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.73, "10th_percentile": 3.73, "90th_percentile": 3.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 3.92, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.92, "10th_percentile": 3.92, "90th_percentile": 3.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 3.92, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.92, "10th_percentile": 3.92, "90th_percentile": 3.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5.26, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.26, "10th_percentile": 5.26, "90th_percentile": 5.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5.26, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.26, "10th_percentile": 5.26, "90th_percentile": 5.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 5.26, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.26, "10th_percentile": 5.26, "90th_percentile": 5.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "Acculink Stent 6-8 x 40mm x 132cm", "code_information": [ { "code": "SUP-115588", "type": "CDM" }, { "code": "C1876", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1822.6, "maximum": 9443.5, "setting": "outpatient", "gross_charge": 9443.5, "discounted_cash": 6610.45, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 9443.5, "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 $9,443.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 9443.5, "10th_percentile": 9443.5, "90th_percentile": 9443.5, "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 $9,443.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 5949.41, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $5,949.41 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 5949.41, "10th_percentile": 5949.41, "90th_percentile": 5949.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $5,949.41 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 9443.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9443.5, "10th_percentile": 9443.5, "90th_percentile": 9443.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 7082.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 7082.63, "10th_percentile": 7082.63, "90th_percentile": 7082.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA APCN/SP", "standard_charge_dollar": 3248.56, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 3248.56, "10th_percentile": 3248.56, "90th_percentile": 3248.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 2866.1, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 2866.1, "10th_percentile": 2866.1, "90th_percentile": 2866.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 3352.44, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 3352.44, "10th_percentile": 3352.44, "90th_percentile": 3352.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 6065.56, "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": 6065.56, "10th_percentile": 6065.56, "90th_percentile": 6065.56, "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": "NWR UHC HMO/PPO", "standard_charge_dollar": 4976.72, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4976.72, "10th_percentile": 4976.72, "90th_percentile": 4976.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 1822.6, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 1822.6, "10th_percentile": 1822.6, "90th_percentile": 1822.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 6610.45, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 6610.45, "10th_percentile": 6610.45, "90th_percentile": 6610.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 6893.76, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 6893.76, "10th_percentile": 6893.76, "90th_percentile": 6893.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 2918.04, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2918.04, "10th_percentile": 2918.04, "90th_percentile": 2918.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 5023.94, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 5023.94, "10th_percentile": 5023.94, "90th_percentile": 5023.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 1860.37, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1860.37, "10th_percentile": 1860.37, "90th_percentile": 1860.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 4721.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 4721.75, "10th_percentile": 4721.75, "90th_percentile": 4721.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 4476.22, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 4476.22, "10th_percentile": 4476.22, "90th_percentile": 4476.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 7554.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 7554.8, "10th_percentile": 7554.8, "90th_percentile": 7554.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 3369.44, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3369.44, "10th_percentile": 3369.44, "90th_percentile": 3369.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 3369.44, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3369.44, "10th_percentile": 3369.44, "90th_percentile": 3369.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 3201.35, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3201.35, "10th_percentile": 3201.35, "90th_percentile": 3201.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 3201.35, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3201.35, "10th_percentile": 3201.35, "90th_percentile": 3201.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 2757.5, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2757.5, "10th_percentile": 2757.5, "90th_percentile": 2757.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 2757.5, "standard_charge_percentage": 29.2, "standard_charge_algorithm": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2757.5, "10th_percentile": 2757.5, "90th_percentile": 2757.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP Implants RC 278; 29.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 4513.99, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4513.99, "10th_percentile": 4513.99, "90th_percentile": 4513.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4513.99, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4513.99, "10th_percentile": 4513.99, "90th_percentile": 4513.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 4513.99, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4513.99, "10th_percentile": 4513.99, "90th_percentile": 4513.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9443.5, "10th_percentile": 9443.5, "90th_percentile": 9443.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9443.5, "10th_percentile": 9443.5, "90th_percentile": 9443.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $9,443.50 @ 12.5% = $1,180.44 due to $0.00 Claim Price", "median_amount": 1180.44, "10th_percentile": 1180.44, "90th_percentile": 1180.44, "count": "0", "methodology": "other", "additional_payer_notes": "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: $9,443.50 @ 12.5% = $1,180.44 due to $0.00 Claim Price" } ] } ] }, { "description": "Acuson AcuNav Volume Intracardiac Echo Catheter 12.5Fr", "code_information": [ { "code": "SUP-373369", "type": "CDM" }, { "code": "C1759", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 2899.58, "maximum": 15023.75, "setting": "outpatient", "gross_charge": 15023.75, "discounted_cash": 10516.62, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 5360.47, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5360.47, "10th_percentile": 5360.47, "90th_percentile": 5360.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 5093.05, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5093.05, "10th_percentile": 5093.05, "90th_percentile": 5093.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA", "standard_charge_dollar": 7316.57, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7316.57, "10th_percentile": 7316.57, "90th_percentile": 7316.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA ASA", "standard_charge_dollar": 7887.47, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7887.47, "10th_percentile": 7887.47, "90th_percentile": 7887.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 5168.17, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 5168.17, "10th_percentile": 5168.17, "90th_percentile": 5168.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 5333.43, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 5333.43, "10th_percentile": 5333.43, "90th_percentile": 5333.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 2899.58, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 2899.58, "10th_percentile": 2899.58, "90th_percentile": 2899.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 12019.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 12019.0, "10th_percentile": 12019.0, "90th_percentile": 12019.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 7181.35, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7181.35, "10th_percentile": 7181.35, "90th_percentile": 7181.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 7181.35, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7181.35, "10th_percentile": 7181.35, "90th_percentile": 7181.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 7181.35, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7181.35, "10th_percentile": 7181.35, "90th_percentile": 7181.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 15023.75, "10th_percentile": 15023.75, "90th_percentile": 15023.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 15023.75, "10th_percentile": 15023.75, "90th_percentile": 15023.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 7917.52, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1424.23, "10th_percentile": 1424.23, "90th_percentile": 1424.23, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 5360.47, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5360.47, "10th_percentile": 5360.47, "90th_percentile": 5360.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 15023.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 15023.75, "10th_percentile": 15023.75, "90th_percentile": 15023.75, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 15023.75, "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 $15,023.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 15023.75, "10th_percentile": 15023.75, "90th_percentile": 15023.75, "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 $15,023.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 7992.64, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 7992.64, "10th_percentile": 7992.64, "90th_percentile": 7992.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 2959.68, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2959.68, "10th_percentile": 2959.68, "90th_percentile": 2959.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 11267.81, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 11267.81, "10th_percentile": 11267.81, "90th_percentile": 11267.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 4642.34, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4642.34, "10th_percentile": 4642.34, "90th_percentile": 4642.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 10516.63, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 10516.63, "10th_percentile": 10516.63, "90th_percentile": 10516.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 10967.34, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 10967.34, "10th_percentile": 10967.34, "90th_percentile": 10967.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 7511.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 7511.88, "10th_percentile": 7511.88, "90th_percentile": 7511.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 4559.71, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 4559.71, "10th_percentile": 4559.71, "90th_percentile": 4559.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 9464.96, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $9,464.96 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 9464.96, "10th_percentile": 9464.96, "90th_percentile": 9464.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $9,464.96 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 9649.75, "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": 9649.75, "10th_percentile": 9649.75, "90th_percentile": 9649.75, "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": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 7121.26, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 7121.26, "10th_percentile": 7121.26, "90th_percentile": 7121.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 5093.05, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5093.05, "10th_percentile": 5093.05, "90th_percentile": 5093.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $15,023.75 @ 12.5% = $1,877.97 due to $0.00 Claim Price", "median_amount": 1877.97, "10th_percentile": 1877.97, "90th_percentile": 1877.97, "count": "0", "methodology": "other", "additional_payer_notes": "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: $15,023.75 @ 12.5% = $1,877.97 due to $0.00 Claim Price" } ] } ] }, { "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": 0.98, "maximum": 5.07, "setting": "outpatient", "gross_charge": 5.07, "discounted_cash": 3.55, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.81, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS HMO", "standard_charge_dollar": 1.81, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 1.97, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.97, "10th_percentile": 1.97, "90th_percentile": 1.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 1.97, "standard_charge_percentage": 38.95, "standard_charge_algorithm": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.97, "10th_percentile": 1.97, "90th_percentile": 1.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 38.95% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.42, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 1.42, "standard_charge_percentage": 28.09, "standard_charge_algorithm": "No historical claim; OP All Other Services; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; 28.09% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 1.8, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 0.98, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% 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 Services; 19.3% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 2.66, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.66, "10th_percentile": 2.66, "90th_percentile": 2.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 1.74, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 1.74, "10th_percentile": 1.74, "90th_percentile": 1.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 2.47, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 1.54, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 1.54, "10th_percentile": 1.54, "90th_percentile": 1.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 2.67, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.67, "10th_percentile": 2.67, "90th_percentile": 2.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.07, "10th_percentile": 5.07, "90th_percentile": 5.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 2.7, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 2.7, "10th_percentile": 2.7, "90th_percentile": 2.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "NWR BEECHSTREET", "standard_charge_dollar": 4.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 4.06, "10th_percentile": 4.06, "90th_percentile": 4.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 2.4, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 2.4, "10th_percentile": 2.4, "90th_percentile": 2.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 1.0, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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; All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 3.55, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 3.55, "10th_percentile": 3.55, "90th_percentile": 3.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 2.54, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 2.54, "10th_percentile": 2.54, "90th_percentile": 2.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 29.49, "standard_charge_algorithm": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 29.49% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 3.7, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 3.7, "10th_percentile": 3.7, "90th_percentile": 3.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 3.8, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 3.8, "10th_percentile": 3.8, "90th_percentile": 3.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 1.57, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "No historical claim; All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR THE ALLIANCE", "standard_charge_dollar": 3.26, "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": 3.26, "10th_percentile": 3.26, "90th_percentile": 3.26, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 5.07, "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 $5.07 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 5.07, "10th_percentile": 5.07, "90th_percentile": 5.07, "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 $5.07 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 3.19, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $3.19 so that total pmt for all claim lines does not exceed 63% 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": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $3.19 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.07, "10th_percentile": 5.07, "90th_percentile": 5.07, "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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.07, "10th_percentile": 5.07, "90th_percentile": 5.07, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.07, "10th_percentile": 5.07, "90th_percentile": 5.07, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "Apex RX Balloon 2.0 x 15mm", "code_information": [ { "code": "SUP-125190", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 70.42, "maximum": 364.86, "setting": "outpatient", "gross_charge": 364.86, "discounted_cash": 255.4, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 71.88, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.88, "10th_percentile": 71.88, "90th_percentile": 71.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 291.89, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 291.89, "10th_percentile": 291.89, "90th_percentile": 291.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 129.53, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 129.53, "10th_percentile": 129.53, "90th_percentile": 129.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 112.74, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 97.08, "10th_percentile": 97.08, "90th_percentile": 97.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 266.35, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 266.35, "10th_percentile": 266.35, "90th_percentile": 266.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 255.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 255.4, "10th_percentile": 255.4, "90th_percentile": 255.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 234.35, "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": 234.35, "10th_percentile": 234.35, "90th_percentile": 234.35, "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": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 191.55, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 191.55, "10th_percentile": 191.55, "90th_percentile": 191.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 192.28, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 192.28, "10th_percentile": 192.28, "90th_percentile": 192.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 125.51, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 125.51, "10th_percentile": 125.51, "90th_percentile": 125.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 273.65, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 273.65, "10th_percentile": 273.65, "90th_percentile": 273.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 194.11, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 194.11, "10th_percentile": 194.11, "90th_percentile": 194.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 110.74, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 110.74, "10th_percentile": 110.74, "90th_percentile": 110.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 182.43, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 182.43, "10th_percentile": 182.43, "90th_percentile": 182.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 172.94, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 172.94, "10th_percentile": 172.94, "90th_percentile": 172.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 177.69, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 177.69, "10th_percentile": 177.69, "90th_percentile": 177.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 70.42, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 70.42, "10th_percentile": 70.42, "90th_percentile": 70.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 229.86, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $229.86 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 229.86, "10th_percentile": 229.86, "90th_percentile": 229.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $229.86 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 364.86, "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 $364.86 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "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 $364.86 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 364.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "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": "NWR BCBS HMO", "standard_charge_dollar": 130.18, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 130.18, "10th_percentile": 130.18, "90th_percentile": 130.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 130.18, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 130.18, "10th_percentile": 130.18, "90th_percentile": 130.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 123.69, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 123.69, "10th_percentile": 123.69, "90th_percentile": 123.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 123.69, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 123.69, "10th_percentile": 123.69, "90th_percentile": 123.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 174.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.4, "10th_percentile": 174.4, "90th_percentile": 174.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 174.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.4, "10th_percentile": 174.4, "90th_percentile": 174.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 174.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.4, "10th_percentile": 174.4, "90th_percentile": 174.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $364.86 @ 12.5% = $45.61 due to $0.00 Claim Price", "median_amount": 45.61, "10th_percentile": 45.61, "90th_percentile": 45.61, "count": "0", "methodology": "other", "additional_payer_notes": "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: $364.86 @ 12.5% = $45.61 due to $0.00 Claim Price" } ] } ] }, { "description": "Apex RX Balloon 2.5 x 15mm", "code_information": [ { "code": "SUP-301832", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 70.42, "maximum": 364.86, "setting": "outpatient", "gross_charge": 364.86, "discounted_cash": 255.4, "payers_information": [ { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 110.74, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 110.74, "10th_percentile": 110.74, "90th_percentile": 110.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 229.86, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $229.86 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 229.86, "10th_percentile": 229.86, "90th_percentile": 229.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $229.86 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 234.35, "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": 234.35, "10th_percentile": 234.35, "90th_percentile": 234.35, "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": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 182.43, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 182.43, "10th_percentile": 182.43, "90th_percentile": 182.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 192.28, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 192.28, "10th_percentile": 192.28, "90th_percentile": 192.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 255.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 255.4, "10th_percentile": 255.4, "90th_percentile": 255.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PPO", "standard_charge_dollar": 266.35, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 266.35, "10th_percentile": 266.35, "90th_percentile": 266.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 112.74, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 97.08, "10th_percentile": 97.08, "90th_percentile": 97.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC CORE", "standard_charge_dollar": 172.94, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 172.94, "10th_percentile": 172.94, "90th_percentile": 172.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 273.65, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 273.65, "10th_percentile": 273.65, "90th_percentile": 273.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 194.11, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 194.11, "10th_percentile": 194.11, "90th_percentile": 194.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 71.88, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.88, "10th_percentile": 71.88, "90th_percentile": 71.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 291.89, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 291.89, "10th_percentile": 291.89, "90th_percentile": 291.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 177.69, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 177.69, "10th_percentile": 177.69, "90th_percentile": 177.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 125.51, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 125.51, "10th_percentile": 125.51, "90th_percentile": 125.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 191.55, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 191.55, "10th_percentile": 191.55, "90th_percentile": 191.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 129.53, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 129.53, "10th_percentile": 129.53, "90th_percentile": 129.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 70.42, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 70.42, "10th_percentile": 70.42, "90th_percentile": 70.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 364.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "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": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 364.86, "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 $364.86 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "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 $364.86 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": "NWR BCBS HMO", "standard_charge_dollar": 130.18, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 130.18, "10th_percentile": 130.18, "90th_percentile": 130.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 130.18, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 130.18, "10th_percentile": 130.18, "90th_percentile": 130.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 123.69, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 123.69, "10th_percentile": 123.69, "90th_percentile": 123.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 123.69, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 123.69, "10th_percentile": 123.69, "90th_percentile": 123.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 174.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.4, "10th_percentile": 174.4, "90th_percentile": 174.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 174.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.4, "10th_percentile": 174.4, "90th_percentile": 174.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 174.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.4, "10th_percentile": 174.4, "90th_percentile": 174.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $364.86 @ 12.5% = $45.61 due to $0.00 Claim Price", "median_amount": 45.61, "10th_percentile": 45.61, "90th_percentile": 45.61, "count": "0", "methodology": "other", "additional_payer_notes": "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: $364.86 @ 12.5% = $45.61 due to $0.00 Claim Price" } ] } ] }, { "description": "Apex RX Balloon 2.5 x 40mm", "code_information": [ { "code": "SUP-313883", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 70.42, "maximum": 364.86, "setting": "outpatient", "gross_charge": 364.86, "discounted_cash": 255.4, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 71.88, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.88, "10th_percentile": 71.88, "90th_percentile": 71.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 291.89, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 291.89, "10th_percentile": 291.89, "90th_percentile": 291.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 129.53, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 129.53, "10th_percentile": 129.53, "90th_percentile": 129.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 112.74, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 97.08, "10th_percentile": 97.08, "90th_percentile": 97.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 266.35, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 266.35, "10th_percentile": 266.35, "90th_percentile": 266.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 255.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 255.4, "10th_percentile": 255.4, "90th_percentile": 255.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 234.35, "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": 234.35, "10th_percentile": 234.35, "90th_percentile": 234.35, "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": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 191.55, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 191.55, "10th_percentile": 191.55, "90th_percentile": 191.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 125.51, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 125.51, "10th_percentile": 125.51, "90th_percentile": 125.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 273.65, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 273.65, "10th_percentile": 273.65, "90th_percentile": 273.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 194.11, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 194.11, "10th_percentile": 194.11, "90th_percentile": 194.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 110.74, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 110.74, "10th_percentile": 110.74, "90th_percentile": 110.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 182.43, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 182.43, "10th_percentile": 182.43, "90th_percentile": 182.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 172.94, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 172.94, "10th_percentile": 172.94, "90th_percentile": 172.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 177.69, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 177.69, "10th_percentile": 177.69, "90th_percentile": 177.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 70.42, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 70.42, "10th_percentile": 70.42, "90th_percentile": 70.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 229.86, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $229.86 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 229.86, "10th_percentile": 229.86, "90th_percentile": 229.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $229.86 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 364.86, "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 $364.86 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "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 $364.86 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 364.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "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": "NWR BCBS HMO", "standard_charge_dollar": 130.18, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 130.18, "10th_percentile": 130.18, "90th_percentile": 130.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 130.18, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 130.18, "10th_percentile": 130.18, "90th_percentile": 130.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 123.69, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 123.69, "10th_percentile": 123.69, "90th_percentile": 123.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 123.69, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 123.69, "10th_percentile": 123.69, "90th_percentile": 123.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 174.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.4, "10th_percentile": 174.4, "90th_percentile": 174.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 174.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.4, "10th_percentile": 174.4, "90th_percentile": 174.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 174.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.4, "10th_percentile": 174.4, "90th_percentile": 174.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $364.86 @ 12.5% = $45.61 due to $0.00 Claim Price", "median_amount": 45.61, "10th_percentile": 45.61, "90th_percentile": 45.61, "count": "0", "methodology": "other", "additional_payer_notes": "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: $364.86 @ 12.5% = $45.61 due to $0.00 Claim Price" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 192.28, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 192.28, "10th_percentile": 192.28, "90th_percentile": 192.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "Apex RX Balloon 3.0 x 15mm", "code_information": [ { "code": "SUP-125194", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 70.42, "maximum": 364.86, "setting": "outpatient", "gross_charge": 364.86, "discounted_cash": 255.4, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 71.88, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.88, "10th_percentile": 71.88, "90th_percentile": 71.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 291.89, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 291.89, "10th_percentile": 291.89, "90th_percentile": 291.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 129.53, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 129.53, "10th_percentile": 129.53, "90th_percentile": 129.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 112.74, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 97.08, "10th_percentile": 97.08, "90th_percentile": 97.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 266.35, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 266.35, "10th_percentile": 266.35, "90th_percentile": 266.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 255.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 255.4, "10th_percentile": 255.4, "90th_percentile": 255.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 234.35, "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": 234.35, "10th_percentile": 234.35, "90th_percentile": 234.35, "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": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 191.55, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 191.55, "10th_percentile": 191.55, "90th_percentile": 191.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 125.51, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 125.51, "10th_percentile": 125.51, "90th_percentile": 125.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 273.65, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 273.65, "10th_percentile": 273.65, "90th_percentile": 273.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 194.11, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 194.11, "10th_percentile": 194.11, "90th_percentile": 194.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 110.74, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 110.74, "10th_percentile": 110.74, "90th_percentile": 110.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 182.43, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 182.43, "10th_percentile": 182.43, "90th_percentile": 182.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA", "standard_charge_dollar": 177.69, "standard_charge_percentage": 48.7, "standard_charge_algorithm": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 177.69, "10th_percentile": 177.69, "90th_percentile": 177.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 48.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA NM EMPLOYEES", "standard_charge_dollar": 70.42, "standard_charge_percentage": 19.3, "standard_charge_algorithm": "All Services; 19.3% Billed", "median_amount": 70.42, "10th_percentile": 70.42, "90th_percentile": 70.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 19.3% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR PHCS PPO", "standard_charge_dollar": 229.86, "standard_charge_percentage": 63.0, "standard_charge_algorithm": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $229.86 so that total pmt for all claim lines does not exceed 63% of claim billed amount.", "median_amount": 229.86, "10th_percentile": 229.86, "90th_percentile": 229.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 63% Billed, and; Pricing Extension - NM HB XR PRC - NWR PHCS LESSOR OF @ 63% OF CHARGES; Note: Paid $229.86 so that total pmt for all claim lines does not exceed 63% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 364.86, "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 $364.86 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "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 $364.86 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "NWR NON-CONTRACTED PAYORS", "standard_charge_dollar": 364.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "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": "NWR BCBS HMO", "standard_charge_dollar": 130.18, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 130.18, "10th_percentile": 130.18, "90th_percentile": 130.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS HMO", "standard_charge_dollar": 130.18, "standard_charge_percentage": 35.68, "standard_charge_algorithm": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 130.18, "10th_percentile": 130.18, "90th_percentile": 130.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 35.68% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BCBS PPO", "standard_charge_dollar": 123.69, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 123.69, "10th_percentile": 123.69, "90th_percentile": 123.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS PPO", "standard_charge_dollar": 123.69, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 123.69, "10th_percentile": 123.69, "90th_percentile": 123.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 33.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 174.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.4, "10th_percentile": 174.4, "90th_percentile": 174.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE SELECT", "standard_charge_dollar": 174.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.4, "10th_percentile": 174.4, "90th_percentile": 174.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "NWR BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 174.4, "standard_charge_percentage": 47.8, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.4, "10th_percentile": 174.4, "90th_percentile": 174.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 47.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 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": "NWR BLUE CROSS MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE HUMANA MEDICARE ADV [2409]", "plan_name": "NWR HUMANA MEDICARE ADVT", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.86, "10th_percentile": 364.86, "90th_percentile": 364.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "NWR MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "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: $364.86 @ 12.5% = $45.61 due to $0.00 Claim Price", "median_amount": 45.61, "10th_percentile": 45.61, "90th_percentile": 45.61, "count": "0", "methodology": "other", "additional_payer_notes": "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: $364.86 @ 12.5% = $45.61 due to $0.00 Claim Price" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 172.94, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 172.94, "10th_percentile": 172.94, "90th_percentile": 172.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% 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." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC HMO/PPO", "standard_charge_dollar": 192.28, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 192.28, "10th_percentile": 192.28, "90th_percentile": 192.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is 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": "Apex RX Balloon 4.0 x 40mm", "code_information": [ { "code": "SUP-313885", "type": "CDM" }, { "code": "C1725", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 70.42, "maximum": 364.86, "setting": "outpatient", "gross_charge": 364.86, "discounted_cash": 255.4, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA ALTERNATIVE", "standard_charge_dollar": 71.88, "standard_charge_percentage": 19.7, "standard_charge_algorithm": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.88, "10th_percentile": 71.88, "90th_percentile": 71.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 19.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR BEECHSTREET", "standard_charge_dollar": 291.89, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 291.89, "10th_percentile": 291.89, "90th_percentile": 291.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA IL PREFERRED", "standard_charge_dollar": 129.53, "standard_charge_percentage": 35.5, "standard_charge_algorithm": "Outpatient; 35.5% Billed", "median_amount": 129.53, "10th_percentile": 129.53, "90th_percentile": 129.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 35.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BROAD", "standard_charge_dollar": 112.74, "standard_charge_percentage": 30.9, "standard_charge_algorithm": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 97.08, "10th_percentile": 97.08, "90th_percentile": 97.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 30.9% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR HFN PPO", "standard_charge_dollar": 266.35, "standard_charge_percentage": 73.0, "standard_charge_algorithm": "All Outpatient Services; 73% Billed", "median_amount": 266.35, "10th_percentile": 266.35, "90th_percentile": 266.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 73% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "NWR HFN PLATINUM EPO", "standard_charge_dollar": 255.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Outpatient Services; 70% Billed", "median_amount": 255.4, "10th_percentile": 255.4, "90th_percentile": 255.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "NWR THE ALLIANCE", "standard_charge_dollar": 234.35, "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": 234.35, "10th_percentile": 234.35, "90th_percentile": 234.35, "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": "AETNA HEALTH PLAN [171]", "plan_name": "NWR AETNA ASA", "standard_charge_dollar": 191.55, "standard_charge_percentage": 52.5, "standard_charge_algorithm": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 191.55, "10th_percentile": 191.55, "90th_percentile": 191.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 52.5% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR UHC HMO/PPO", "standard_charge_dollar": 192.28, "standard_charge_percentage": 52.7, "standard_charge_algorithm": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 192.28, "10th_percentile": 192.28, "90th_percentile": 192.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 52.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser 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": "NWR AETNA APCN/SP", "standard_charge_dollar": 125.51, "standard_charge_percentage": 34.4, "standard_charge_algorithm": "Outpatient; 34.4% Billed", "median_amount": 125.51, "10th_percentile": 125.51, "90th_percentile": 125.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 34.4% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "NWR CIGNA BEHAVORIAL BHS", "standard_charge_dollar": 273.65, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Unassigned Service OP; 75% Billed", "median_amount": 273.65, "10th_percentile": 273.65, "90th_percentile": 273.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Unassigned Service OP; 75% Billed" }, { "payer_name": "CHOICECARE [177]", "plan_name": "NWR CHOICE CARE", "standard_charge_dollar": 194.11, "standard_charge_percentage": 53.2, "standard_charge_algorithm": "Outpatient; 53.2% Billed", "median_amount": 194.11, "10th_percentile": 194.11, "90th_percentile": 194.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 53.2% Billed" }, { "payer_name": "MERCY CARE HEALTH PLANS [5013]", "plan_name": "NWR MERCY CARE", "standard_charge_dollar": 110.74, "standard_charge_percentage": 30.35, "standard_charge_algorithm": "Outpatient; 30.35% Billed", "median_amount": 110.74, "10th_percentile": 110.74, "90th_percentile": 110.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 30.35% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "NWR SEIU HEALTHLINK", "standard_charge_dollar": 182.43, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 182.43, "10th_percentile": 182.43, "90th_percentile": 182.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "NWR UHC CORE", "standard_charge_dollar": 172.94, "standard_charge_percentage": 47.4, "standard_charge_algorithm": "Table 5 Services; 47.4% 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": 172.94, "10th_percentile": 172.94, "90th_percentile": 172.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 47.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is